HomeMy WebLinkAboutA7116 - GROUP HEALTH CARE BENEFT PLAN WITH BLUE SHIELD OF CA (W0002421-M0021447) APPLICATION IS HEREBY MADE TO
Blue Shield of California
(California Physicians' Service)
FOR A GROUP HEALTH SERVICE CONTRACT
BY: City of Palm Springs
3200 E.Tahquitz Canyon Way
Palm Springs,CA 92262
This Contract, number W0002421-M0021447, shall be effective January 1,2020. It has been read and approved, and the
terms and conditions are accepted by the Contractholder.
The Contractholder, on behalf of itself and its Subscribers, hereby expressly acknowledges its understanding that this
agreement constitutes a Contract solely between the Contractholder and Blue Shield of California(hereafter referred to as
"the Plan"),which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association
("Association"),an Association of independent Blue Cross and Blue Shield plans,permitting the Plan to use the Blue Shield
Service Mark in the State of California,and that the Plan is not contracting as the agent of the Association.The Contmctholder
further acknowledges and agrees that it has not entered into this agreement based upon representations by any person other
than the Plan and that neither the Association nor any person,entity, or organization affiliated with the Association,shall be
held accountable or liable to the Contractholder or its Subscribers for any of the Plan's obligations to the Contractholder
created under this agreement. This paragraph shall not create any additional obligations whatsoever on the part of the Plan,
other than those obligations created under other provisions of this agreement.
The Contractholder shall sign, date and return this original application page to Blue Shield of California, 601 121h
Street, 2011 Floor, Oakland, CA 94607, Attention: Product Operations. The Contract shall be retained by the
Contractholder. Payment of Dues and acceptance of Blue Shield's performance hereunder by the Contractholder shall be
deemed to constitute the Contractholder's acceptance of the terms hereof, whether or not this agreement is signed by the
Contractholder.
The Contractholder is responsible for communicating any changes to Benefits as set forth in Part IX., Contractholder
Responsibility for Distribution and Notification Requirements.Please see this section for important timelines for distribution
of information.
It is agreed that this application supersedes any previous application for this Contract.
Dated at ��+ /i✓GJ <--1y (City,State)
this /C day of
/ (I egal Name of Contmctholder)
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PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF
CALIFORNIA AT THE ABOVE ADDRESS.RETAIN THE CONTRACT.
Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield
of California at the address provided on page GC-1.
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blue Q of california
601 1211 Street
Oakland, CA 94607
(510) 607-2000
GROUP HEALTH SERVICE CONTRACT
Blue Shield of California PPO Plan
between
City of Palm Springs
(`Contraciholder^)
and
California Physicians'Service
dba Blue Shield of California
a not-for-profit corporation
In consideration of the applications and the timely payment of Dues,Blue Shield agrees to provide Benefits of this
Contract to covered Employees and their covered Dependents.
This Contract shall be effective as of January 1,2020, for a term of 12 months, subject to the provisions entitled,
"Changes:Entire Contract".
Jason Bleou
Vice President
Core Accounts
Blue Shield of California
Group Number:W0002421-M0021447
Original Effective Date:July 1,1998
GC-1
IMPORTANT
No person has the right to receive the Benefits of this Contract for Services or supplies furnished following termination of
coverage, except as specifically provided in the Group Continuation Coverage and Extension of Benefits sections of the
Evidence of Coverage and Disclosure Form (EOC). Benefits of this Contract are available only for Services and supplies as
included in the applicable sections of the EOC, furnished during the term the Contract is in effect and while the individual
claiming Benefits is actually covered by this Contract. Benefits may be modified during the term of this Contract under the
applicable section in Part V.Dues,Part VIII.General Provisions,D.Changes:Entire Contract,or upon renewal.If Benefits are
modified,the revised Benefits(including any reduction in Benefits or the elimination of Benefits)apply for Services or supplies
furnished on or after the effective date of the modification.There is no vested right to receive the Benefits of this Contract.
C-1
TABLE OF CONTENTS
Paee C-
PARTI. INTRODUCTION.........................................................................................................................4
PARTII. DEFINITIONS.............................................................................................................................4
PARTTII.ELIGIBILITY.............................................................................................................................5
A. Employee Eligibility,Waiting Periods and Open Enrollment........................................................................................5
B. Associated Employers.....................................................................................................................................................6
C. Termination of Benefits..................................................................................................................................................7
PART IV. GROUP RENEWAL PROVISIONS .........................................................................................8
A. Advance Notification of Blue Shield's Intent to Renew the Group Health Service Contract........................................8
B. Renewal of the Group Health Service Contract..............................................................................................................8
PARTV. DUES...........................................................................................................................................9
PART VI. INTER-PLAN ARRANGEMENTS (BLUECARD(D PROGRAM AND OTHERS) .............10
PART VII. CANCELLATION/REINSTATEMENT/GRACE PERIOD..................................................12
A. Cancellation Without Cause..........................................................................................................................................12
B. Cancellation for Non-Payment of Dues........................................................................................................................12
C. Cancellation/Rescission for Fraud,Intentional Misrepresentations of Material Fact...................................................12
D. Grace Period..................................................................................................................................................................12
E. Payment or Refund of Dues Upon Cancellation...........................................................................................................12
F. Termination of Benefits................................................................................................................................................12
G. Employer to Provide Subscribers with Notice Confirming Termination of Coverage.................................................12
PART VIII. GENERAL PROVISIONS ....................................................................................................13
A. Choice of Providers.......................................................................................................................................................13
B. Use of Masculine Pronoun............................................................................................................................................13
C. Workers'Compensation................................................................................................................................................13
D. Changes:Entire Contract..............................................................................................................................................13
E. Statutory Requirements.................................................................................................................................................13
F. Legal Process................................................................................................................................................................14
G. Time of Commencement or Termination......................................................................................................................14
H. Records and Information to be Furnished.....................................................................................................................14
1. Inquiries and Complaints..............................................................................................................................................14
J. Confidentiality..............................................................................................................................................................14
K. ERISA Plan Administrator............................................................................................................................................14
L. Special Cases: Value-Based Programs .........................................................................................................................14
M. Producer Service Fee....................................................................................................................................................15
PART IX. CONTRACTHOLDER RESPONSIBILITY FOR DISTRIBUTION AND NOTIFICATION
REQUIREMENTS.....................................................................................................................................17
A. Obtaining Declinations or Waivers of Coverage..........................................................................................................17
B. Distribution of Summary of Benefits and Coverage(SBC).........................................................................................17
C. Distribution of Member ID Cards and EOC Booklets..................................................................................................17
D. Notice of Cancellation for Nonpayment of Premiums and Grace Period or Notice of Cancellation,Rescission or
Nonrenewal.........................................................................................................................................................................18
E. Notification of COBRA and Cal-COBRA Coverage Option and Other COBRA/Cal-COBRA Notices.....................18
EVIDENCE OF COVERAGE AND DISCLOSURE FORM...................................................................20
Refer to the Table of Contents in the EOC
Supplements:
Outpatient Prescription Drugs
C-2
PART I. INTRODUCTION
This Blue Shield of California Health Plan will provide or arrange for the provision of Services to eligible Subscribers and
Dependents of the Contractholder in accordance with the terms,conditions, limitations,and exclusions of this Group Health
Service Contract.
The Evidence of Coverage and Disclosure Form(EOC)is included and made part of this Contract.
PART H.DEFINITIONS
In addition to the provisions contained in the"Definitions" section of the EOC,the following provisions apply to this Group
Health Service Contract:
Employee-(1)an individual engaged on a full-time basis in the conduct of the business of the Employer,whose normal work
week is at least 30 hours,and whose duties in such employment are performed at the Employer's regular places of business;or
(2)a sole proprietor or partner ofa partnership engaged on a full-time basis, at least 30 hours per week, in the Employer's
business and who is included as an Employee under a health care Plan Contract of the Employer.
An individual is ineligible for coverage who works part-time,temporary,or is employed on a substitute basis.
C-4
PART III. ELIGIBILITY
A. Employee Eligibility,Waiting Periods and Open Enrollment
In addition to the provisions contained in the Eligibility section of the EOC,the following provisions apply to this Group
Health Service Contract:
I. The date of eligibility of Employees who enroll during the initial enrollment period shall be determined as follows:
a. Inasmuch as this Contract replaces a Contract between Blue Shield and the Employer, each individual in the
employ of the Employer on the effective date of this Contract who was a Subscriber of Blue Shield by virtue
of the Employer's previous Contract on the date immediately preceding the effective date of this Contract,who
lives and/or works in the Plan Service Area is eligible on the effective date of this Contract.
b. Each individual,except as provided in paragraph a. above,shall be eligible to enroll on the first of the month
following the completion of any applicable waiting period established by the Employer.
C. If associated Employers are added,the effective date of the amendment adding an associated Employer shall
be treated as the effective date of this Contract for the purpose of determining the date of eligibility of the
Employees of such Employer.
2. The date of eligibility of a former Employee, who has been re-employed, shall be determined as follows: The
Employee's period of service prior to termination of employment shall be included in the determination of his date
of eligibility,provided:
a. he has resumed active work within 6 months after such termination;or
b. if his previous employment was terminated due to entry into the Armed Forces, he has resumed active work
within the time set by law for reinstatement of employment rights.However,there will be no waiting periods
as prohibited by The Military&Veterans Code;or
C. if termination was due to disability,he has resumed active work within one month after ceasing to be disabled;
otherwise he shall be considered as an Employee entering the employ of the Employer on the date he resumed work
and shall be eligible on the date he completes the period of service specified in A.l.b.
3. If any class of Employees is not eligible under A.1., and if an Employee transfers from such ineligible class to an
eligible class, he shall be considered as having entered the employ of the Employer on the date of such transfer.
Service in an ineligible class shall not be included in the determination of the date of eligibility.
4. The Employer agrees to offer health Benefits coverage to all eligible Employees during the initial enrollment period
and distribute information as set forth in Part IX., Contractholder Responsibility for Distribution and Notification
Requirements.In addition,the Employer agrees to get the Employee's signed acknowledgment of an explicit written
notice in bold type specifying that failure to elect coverage during the initial enrollment period permits the Plan to
impose,at the time of the Employee's later decision to elect coverage,an exclusion from coverage for a period of 12
months, or at the Employer's next Open Enrollment Period, whichever is earlier, unless the Employee meets the
criteria specified in paragraph 1. of the definition of Late Enrollee. Blue Shield will not consider applications for
earlier effective dates.
5. An Employee may transfer enrollment for himself or his Dependent(s)from another group health plan sponsored by
the Employer to the health Plan covered by this Contract only during the Open Enrollment Period from December
l through December 31 of each year. The effective date of Benefits for such Employee and Dependent(s)shall be
the first day of each subsequent January. Submission of evidence of acceptability is not required when application
is made during this Open Enrollment Period.
6. The Employer shall timely report any additions or terminations of Employees or Dependents so that retroactive Dues
adjustments are avoided and claims are not paid for ineligible individuals.However,if the Employer determines that
it has made an administrative error in the processing of eligibility for an Employee or Dependent,Blue Shield will
accept the retroactive changes subject to the following limitations:
C-5
PART III. ELIGIBILITY
a. Blue Shield will accept enrollment of the Employee or Dependent retroactively for a maximum of 60 days,as
long as Dues are paid by the Employer for the entire retroactive enrollment period. If an Employee or
Dependent is retroactively enrolled pursuant to this,and the Employee or Dependent received covered health
care services during that retroactive period, Blue Shield will reimburse the Employee for payments made for
Covered Services received in accordance with the rules of the EOC, minus the Member's Copayments or
Coinsurance as stated in the EOC;
b. Blue Shield will accept termination/disenrollment of the Employee or Dependent retroactive for a maximum
of 60 days and will refund appropriate Dues paid for the retroactive termination period. In such case, Blue
Shield reserves the right to request refund from the Employee for any payments made for services rendered
during the retroactive termination period. In making a request for retroactive termination or disenrollment,
Contractholder shall comply with all applicable state and federal law,including,but not limited to,the Patient
Protection&Affordable Care Act and any related regulations.
7. The Employer agrees to comply with the requirements of Section 2708 of the Patient Protection&Affordable Care
Act (Section 2708), which prohibits an employer from imposing a prohibited waiting period. "Waiting period"
means a period that is required to pass before an otherwise eligible Employee will be able to enroll in coverage under
the Group Contract.Specifically,Employer agrees:
a. Any conditions of eligibility or waiting periods imposed on the eligible Employee will comply with the
requirements of Section 2708 and California state law and any rules and regulations implementing those
requirements.
b. Employer will notify Blue Shield if Employer imposes a waiting period on an eligible Employee that would
exceed the time-period permitted by Section 2708.
C. The Employer must ensure that any orientation period that may be imposed by the Employer prior to the start
of the waiting period is consistent with federal regulations. The Employer will notify Blue Shield of the
Employee's eligibility for coverage after the orientation period.
d. Employer will notify Blue Shield if any changes are made regarding these representations.
e. Employer will hold Blue Shield harmless for any violation of the requirements of Section 2708 or California
state law.
B. Associated Employers
Employees of the following listed Employers associated with the Employer as subsidiaries or affiliates are eligible for
Benefits in accord with this Contract.For the purposes of this Contract only,service with any associated Employers shall
be considered service with the Employer. The Employer may act for and on behalf of any associated Employers in all
matters pertaining to this Contract, and every act done by,agreement made with,or notice given to the Employer shall
bind all associated Employers.
list of associated Employers
None
C-6
PART III. ELIGIBILITY
C. Termination of Benefits
In addition to the provisions contained in the Termination of Benefits section of the EOC,the following provisions
apply to this Group Health Service Contract:
1. The Benefits of a Member shall cease on the first day of the month following the month in which the Subscriber
retires,is pensioned,leaves voluntarily,or is dismissed from the employ of the Contmctholder or otherwise ceases
to be a member of a class eligible for coverage,unless a different date on which the Subscriber no longer meets the
requirements for eligibility has been agreed to between Blue Shield and the Contractholder,except that:
a. if the Subscriber ceases active work because of a disability due to illness or bodily injury, or because of an
approved leave of absence or temporary layoff,payment of Dues for that Subscriber shall continue coverage
in force in accordance with the Employer's policy regarding such coverage;or,
b. if the Employer is subject to the California Family Rights Act of 1991 and/or the Federal Family&Medical
Leave Act of 1993, and the approved leave of absence is for family leave pursuant to such Acts,payment of
Dues for that Subscriber shall keep coverage in force for the duration(s)prescribed by the Acts.The Employer
is solely responsible for notifying Employees of the availability and duration of family leaves.
2. With respect to a newborn child or a child placed for adoption, coverage will cease on the 31"day at 11:59 p.m.
Pacific Time following the Dependent's effective date of coverage,except that coverage shall not cease if a written
or electronic application for the addition of the Dependent is submitted to and received by Blue Shield within 31
days following the effective date of coverage.
C-7
PART IV. GROUP RENEWAL PROVISIONS
A. Advance Notification of Blue Shield's Intent to Renew the Group Health Service Contract
The Employer shall be notified by Blue Shield of its intent to renew this Group Health Service Contract at least 90 days
prior to the proposed effective date of the renewal.However,this renewal advance notification is distinct from,and does
not alter the notification periods specified in Part V.Dues,Paragraph D.,or in Part VIII. General Provisions,Paragraph
D. Changes: Entire Contract.
B. Renewal of the Group Health Service Contract
Blue Shield will renew this Group Health Service Contract at the option of the Contractholder except in the following
instances:
1. the Contractholder violates a material contract provision relating to Employer or other group contributions or group
participation rates by the Contractholder or Employer;
2. the Contractholder fails to pay the.required Dues as specified under Part V.Dues;
3. the Contractholder commits fraud or other intentional misrepresentation of material fact;
4. the Contractholder relocates outside of California;
5. Blue Shield ceases to offer a plan type purchased by the Contractholder,
6. Blue Shield ceases to offer health benefit plans in the state(withdrawal of all products).
C-8
PART V. DUES
A. Dues
Monthly Dues
M0021447
Subscriber..................................................................................................................$1,092.17
Additional for one Dependent...................................................................................$1,004.20
Additional for two or more Dependents....................................................................$1,129.33.
B. When and Where Payable
1. The initial Dues are due on the effective date of this Contract and subsequent Dues shall be due on the same date of
each succeeding month("the first month's transmittal date")thereafter,provided that the Dues due on any transmittal
date shall not be deemed to have been paid unless the total Dues for all parts in force on such transmittal date have
been paid.
2. Dues for Employees and/or Dependents who become eligible on a date other than the bill date are waived for the
month during which eligibility for covered Benefits is attained. Dues for Employees and/or Dependents whose
eligibility for covered Benefits terminates on a date other than the bill date are due in full for the month during which
eligibility is terminated.
3. All Dues are payable.by the Employer to Blue Shield of California.The payment of any Dues shall not maintain the
Benefits under this Contract in force beyond the date immediately preceding the next transmittal date except as
otherwise provided in Part V.F.
C. The terms of this Contract or the Dues payable therefor may be changed from time to time as set forth in Part VIII.,D.
Changes:Entire Contract.
1). The Employer shall remit to Blue Shield the amount specified in Part V.A.("the Dues").If a Federal, State or any other
taxing or licensing authority imposes upon Blue Shield any tax or fee on account of any of the Employer's health benefit
plans that is not included in the Dues,whether such tax or fee is based on Dues,gross receipts, enrollment or any other
basis, Blue Shield may amend the Contract to increase the Dues by an amount sufficient to cover any such tax or fee
rounded to the nearest cent.This amendment shall be effective as of the date stated in the notice,which shall not be earlier
than the date of the imposition of such tax or fee,by mailing a postage prepaid notice of the amendment to the Employer
at its address of record with Blue Shield at least 60 days before the effective date of the amendment.In the case of Federal
excise taxes, Blue Shield.may also amend the Dues to include any increased Federal income taxes to Blue Shield
associated with such Federal excise taxes.
E. If benefit amounts are changed due to a change in the terms of this Contract or if a tax is levied under Part V.D.,the Dues
charged therefor may be made,or the Dues credit therefor may be given,as of the effective date of such change.
F. A grace period of 30 days to pay all delinquent Dues and avoid cancellation will be granted for the payment of Dues
accruing other than those due on the effective date of this Contract, during which period this Contract shall continue in
force,but the Employer shall be liable to Blue Shield for the payment of all Dues accruing during the period the Contract
continues in force during the grace period-. Cancellation for non-payment of Dues shall be in accordance with PART
VII.B.
C-9
PART VI. INTER-PLAN ARRANGEMENTS (BLUECARD®PROGRAM AND OTHERS)
Out-of-Area Services
Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as Inter-
Plan Arrangements.Whenever a Member accesses Covered Services outside of California,the claim for those services may be
processed through one of these Inter-Plan Arrangements and presented to Blue Shield for payment in accordance with the Blue
Cross Blue Shield Association rules and procedures then in effect.The Inter-Plan Arrangements available to Members under
this agreement are described generally below.
When Members access Covered Services outside of California,within the BlueCard Service Area,they may obtain care from
participating health care providers that have a contractual agreement with the local Blue Cross and/or Blue Shield Licensee in
that other geographic area(Host Blue). In some instances, Members may obtain care from health care providers in the Host
Blue geographic area that do not have a contractual agreement with the Host Blue(non-participating providers).Blue Shield's
payment practices in both instances are described below.
BlueCard®Program
The BlueCard'O Program is an Inter-Plan Arrangement.Under this arrangement,when Members access Covered Services within
the geographic area served by a Host Blue, Blue Shield will remain responsible for fulfilling our contractual obligations.
However,the Host Blue will be responsible for providing such services as contracting and handling substantially all interactions
with its participating health care providers.
The financial terms of the BlueCard Program are described generally below.
Liability Calculation Method Per Claim
Calculation of Member liability on claims for Covered Services processed through the BlueCard Program, if not a flat dollar
copayment, will be based on the lower of the participating provider's billed charges for Covered Services or the negotiated
price made available to Blue Shield by the Host Blue.The negotiated price may represent one of the following:
(i) an actual price.An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other
increases or decreases,or
(ii) an estimated price.An estimated price is a negotiated rate of payment in effect at the time a claim is processed,reduced,
or increased by a percentage to take into account certain payments negotiated with the provider and other claim-and non-
claim-related transactions.Such transactions may include,but are not limited to,anti-fraud and abuse recoveries,provider
refunds not applied on a claim-specific basis,retrospective settlements,and performance-related bonuses or incentives;
or
(iii) an average price. An average price is a percentage of billed charges for Covered Services in effect at the time a claim is
processed representing the aggregate payments negotiated by the Host Blue with all of its health care providers or a similar
classification of its providers and other claim-and non-claim-related transactions.Such transactions may include the same
ones as noted above for an estimated price.
Host Blues determine whether or not they will use an actual price,estimated price,or average price.Host Blues using either an
estimated price or an average price may prospectively increase or reduce such prices to correct for over-or underestimation of
past prices(i.e.,a prospective adjustment may mean that a current price reflects additional amounts or credits for claims already
paid to providers or anticipated to be paid to or received from providers). However,the BlueCard Program requires that the
amount paid by the Member is a final price; no future price adjustment will result in increases or decreases to the pricing of
past claims.The method of claims payment by Host Blues is taken into account by Blue Shield in determining the Employer's
Premiums.
Inter-Plan Arrangements: Federal/State Taxes/Surcharges/Fees
In some instances,federal or state laws or regulations may impose a surcharge,tax,or other fee that applies to insured accounts.
If applicable,Blue Shield will include any such surcharge,tax,or other fee in determining Employer's Premiums.
Special Cases:Value-Based Programs
C-10
PART VI. INTER-PLAN ARRANGEMENTS (BLUECARD®PROGRAM AND OTHERS)
Blue Shield has included a factor for bulk distributions from Host Blues in the premium for Value-Based Programs when
applicable under this agreement.
Non-Participating Providers Outside of California
When Covered Services,other than Emergency Services,are received from non-participating providers outside of California,
but within the BlueCard Service Area,the amount(s) a Member pays for such services will generally be based on the Host
Blue's non-participating provider local payment, the Allowable Amount Blue Shield pays a Non-Participating provider in
California if the.Host Blue has no non-participating provider allowance, or the pricing arrangements required by applicable
state law.In these situations,the Member may be responsible for the difference between the amount that the non-participating
provider bills and the payment Blue Shield will make for the Covered Services as set forth in this paragraph.
Claims for covered Emergency Services are paid based on the Allowable Amount as defined in the EOC.
Blue Shield Global Core
If Members are outside the BlueCard Service Area, they may be able to take advantage of Blue Shield Global Core when
accessing Out-of-Area Covered.Health Care Services. Blue Shield Global Core is unlike the BlueCard Program available in
the BlueCard Service Area. Although Blue Shield Global Core assists Members with accessing a network of inpatient,
outpatient, and professional providers,the network is not served by aHost Blue plan. As such, when Members receive care
from providers outside the BlueCard Service Area,Members will typically have to pay the providers and submit the claims
themselves to obtain reimbursement for these services.Details for Blue Shield Global Core claim submission are provided in
the Inter-Plan Arrangements section of the EOC.
C-11
PART VII. CANCELLATION/REINSTATEMENT/GRACE PERIOD
A. Cancellation Without Cause
The Employer may cancel this Contract at any time by written notice delivered or mailed to Blue Shield, effective on
receipt or on such later date as specified in the notice.
B. Cancellation for Non-Payment of Dues
Blue Shield may cancel this Contract for non-payment of Dues. If Dues are not received when due,coverage will end 30
days after the date for which Dues are due.The Employer will be liable for all Dues accrued while this Contract continues
in force including those accrued during the 30-day grace period. In such case, a Notice Confirming Termination of
Coverage will be mailed to the Employer by Blue Shield.A new application for coverage will be required by the Employer
and a new Contract will be issued only upon demonstration that the Employer meets all underwriting requirements at the
time of application.
C. Cancellation/Rescission for Fraud,Intentional Misrepresentations of Material Fact
Blue Shield may cancel or rescind this Contract within 24 months following issuance for fraud or intentional
misrepresentation of material fact by the Employer;or with respect to coverage of Employees or Dependents,for fraud or
intentional misrepresentation of material fact by the Employee, Dependent, or their representative. Fraud or intentional
misrepresentations of material fact on an application or a health statement (if a health statement is required by the
Employer)may,at the discretion of Blue Shield,result in the cancellation or rescission of this Contract.A rescission voids
the Contract retroactively as if it was never effective;Blue Shield will provide written notice prior to any rescission.
D. Grace Period
The Employer shall be entitled to a grace period of 30 days for payment of Dues, as described in PART V.F. hereof.If
during a grace period written notice is given by the Employer to Blue Shield that the Contract or(subject to the consent of
Blue Shield)any part of the Contract is to be discontinued before the expiration date of the grace period,the Contract or
such part shall be discontinued as of the date specified by the Employer or the date of receipt of such written notice by
Blue Shield,whichever is the later date,and the Employer shall be liable to Blue Shield for the payment of pro rata Dues
for the period commencing with the last transmittal date and ending with the date of such discontinuance.
E. Payment or Refund of Dues Upon Cancellation
In the event of cancellation,the Employer shall promptly pay any earned Dues which have not previously been paid.Blue
Shield shall within 30 days of cancellation(I)return to the Employer the amount of prepaid Dues,if any,that Blue Shield
determines have not been earned as of the effective date of cancellation,and(2)provide Benefits of the Plan for Services
incurred during the time coverage was in effect up to and including the effective date of cancellation.
F. Termination of Benefits
No Benefits shall be provided for Services rendered after the effective date of cancellation,except as specifically provided
in the Group Continuation of Coverage and Extension of Benefits sections of the EOC.
In the event this Contract is cancelled for any reason, including but not limited to for non-payment of Dues, no further
Benefits will be provided after cancellation unless the Member is a registered Inpatient or is undergoing treatment for an
ongoing condition and obtains an extension of Benefits in accordance with the Extension of Benefits section of the EOC.
G. Employer to Provide Subscribers with Notice Confirming Termination of Coverage
If this Contract is rescinded, or cancelled by either party, the Employer shall notify the Subscribers. If rescinded or
cancelled by Blue Shield, the Employer shall promptly mail a copy of Blue Shield's Notice Confirming Termination of
Coverage to each Subscriber and provide Blue Shield proof of such mailing and the date thereof.
C-12
PART VIII. GENERAL PROVISIONS
In addition to the provisions contained in the EOC,the following provisions apply to this Group Health Service Contract:
A. Choice of Providers
A Subscriber or Dependent may select any Hospital or Physician to provide covered Services hereunder, including
providers outside of California. Benefits differ depending on whether a Participating Provider or a Non-Participating
Provider is selected.It is to the Subscribers advantage to select Participating Providers whenever possible.A Participating
Provider Directory is available to all Subscribers by calling Blue Shield at(800)331-2001 or writing to them at:
P.O.Box 70850
Oakland,CA 94612
or
P.O.Box 92945
Los Angeles,CA 90009
In the event that the inability to perform of a Participating Provider,the breach of the Contract to furnish Services by a
Participating Provider, or the termination of a Participating Provider's Contract with Blue Shield may materially and
adversely affect the Employer,Blue Shield will,within a reasonable time,advise the Employer in writing of such inability
to perform,breach,or termination.
B. Use of Masculine Pronoun
Whenever a masculine pronoun is used in this Contract, it shall include the feminine gender unless the context clearly
indicates otherwise.
C. Workers' Compensation
This Contract is not in lieu of,and shall not affect,any requirements for coverage by Workers' Compensation Insurance.
D. Changes: Entire Contract
This Contract, including appendices, attachments, or other documents incorporated by reference constitutes the entire
agreement between the parties, and any statement made by the Employer or by any Subscriber shall, in the absence of
fraud,be deemed a representation and not a warranty.
The terms of this Contract,the Dues payable therefor, and the benefits of this Plan, including but not limited to Covered
Services,Deductible,Copayment and annual Out-of-Pocket Maximum amounts,may be changed from time to time.Blue
Shield will provide at least 60 days'written notice of any such change,and these changes shall not become effective until
at least 60 days after written notice of such change is delivered or mailed to the Employers last address as shown on the
records of Blue Shield.Benefits for services furnished on or after the effective date of any Benefit modification shall be
provided based on the modification.No change in this Contract shall be valid unless approved by an executive officer of
Blue Shield and a written endorsement is issued.No other representative has authority to change this Contract or to waive
any of its provisions.
Notice of changes in Benefits,and any documents that may be delivered to the Employer or the Employer's representative
for the purpose of informing Members of the details of their coverage under this Contract, will be distributed by the
Employer or his representative as set forth in Part IX., Contractholder Responsibility for Distribution and Notification
Requirements.
E. Statutory Requirements
This Contract is subject to the requirements of the Knox-Keene Health Care Service Plan Act,Chapter 2.2 of Division 2
of the California Health and Safety Code and Title 28 of the California Code of Regulations.Any provision required to
be in this Contract by reason of the Act or Regulations shall bind Blue Shield whether or not such provision is actually
included in this Contract.In addition,this Contract is subject to applicable state and federal statutes and regulations,which
may include the Employee Retirement Income Security Act, Health Insurance Portability and Accountability Act
C-13
PART VIII. GENERAL PROVISIONS
("H1PAA")and applicable Centers for Medicare and Medicaid Services("CMS")requirements.Any provision required
to be in this Contract by reason of such state and federal statutes shall bind the Group and Blue Shield whether or not
such provision is actually included in this Contract.
F. Legal Process
Legal process or service upon Blue Shield must be served upon a corporate officer of Blue Shield.
G. Time of Commencement or Termination
Wherever this Contract provides for a date of commencement or termination of any part or all of this Contract,
commencement or termination shall be effective as of 12:01 a.m.Pacific Time ofthe commencement date and as of 11:59
p.m.Pacific Time of the termination date.
H. Records and Information to be Furnished
The Employer shall furnish Blue Shield with such information as Blue Shield may require to enable it to administer this
Plan,to determine the Dues and to enable it to perform this Contract.CMS specifically requires Blue Shield to obtain the
following information: Social Security numbers for Subscribers and dependents over forty-five (45) years of age,
Subscriber employment status, Employer identification number and Employer size. Failure to provide any such
information required by this Section may result in immediate Cancellation of this Contract.
1. Inquiries and Complaints
Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue
Shield at the address or telephone number indicated on page GC-1 of this Contract.(See also the Customer Service section
of the EOC.)
J. Confidentiality
The Contractholder shall comply with all applicable state and federal laws regarding the privacy and confidentiality of
the personal and health information of Subscribers and Dependents. The Contractholder shall not require the Plan to
release the personal and health information of individual Subscribers or Dependents without written authorization from
the Subscriber,unless permitted by law.No information may be disclosed by either party in violation of Cal.Civ. Code
§§56,et seq.At the request of the Contractholder,the Plan may provide aggregate,encrypted,or encoded data regarding
Subscribers and Dependents to the Contractholder, unless such data would explicitly or implicitly identify specific
Subscribers or Dependents. To the extent the Contractholder receives, maintains, or transmits personal or health
information of Subscribers or Dependents electronically,the Contractholder shall comply with all state and federal laws
relating to the protection of such information including, but not limited to, the Health Insurance Portability and
Accountability Act(HIPAA)provisions on security and confidentiality.
K ERISA Plan Administrator
If the Contractholder's Plan is governed by ERISA (29 USC Sections 1001,et seq.), it is understood that Blue Shield is
not the plan administrator for the purposes of ERISA.The plan administrator is the Contractholder.
L. Special Cases:Value-Based Programs
Enrollees may access covered services from providers that participate in a Blue Shield Value-Based Program.Blue Shield
Value-Based Programs include,but are not limited to,Accountable Care Organizations,Episode Based Payments,Patient
Centered Medical Homes and Shared Savings arrangements.
Blue Shield has included any associated costs in the Premium for Blue Shield Value-Based Programs when applicable
under this agreement.
C-14
PART VIII. GENERAL PROVISIONS
M. Producer Service.Fee
The Contractholder has selected and entered into an agreement with Wells Fargo Insurance Services,USI California
Ins Services("Producer"),under which the Producer has agreed to provide consulting services to the Contractholder in
connection with the Contractholder's Plan(s)(the"Service Agreement"), in return for payment from the Contractholder
of compensation negotiated directly between theContractholder and the Producer(the"Fee"). Blue Shield is not a party
to the Service Agreement.
The Contractholder requests that Blue Shield receive from the Contractholder and pay to the Producer certain amounts
comprising payment for the Producer's services..under the Service Agreement (the "Pass-Through Arrangement" or
"Arrangement").
1. Blue Shield Duties and Responsibilities:
a. Blue Shield agrees to accept from the Contractholder payment of the monthly Fee amount with the
Contractholder's payment of Blue Shield's monthly Premium invoice to the Contractholder.
b. Blue Shield will forward the Fee to the Producer within 30 days of receipt of the Fee from the Contractholder.
C. Blue Shield will provide to the Contractholder a summary of the aggregate Fee paid by Blue Shield on behalf
of the Contractholder to the Producer for each Calendar Year within 15 business days following the end of
such Calendar Year.
d. Blue Shield is not responsible for determining or confirming the correctness of any information provided by
the Contractholder,including the amount of the Fee or the name or other payment information of the Producer
to whom the Fee is to be paid;rather,Blue Shield is responsible only for the ministerial functions of receiving
payment of the Fee and forwarding such payment to the Producer.
2. The Contractholder Duties and Responsibilities:
a. The Contractholder acknowledges and agrees that the Fee is not a part of the Premium charged to the
Contractholder by Blue Shield,that using the Producer or any other agent or broker is not a requirement for
the Contractholder to obtain coverage from Blue Shield and the Contractholder may obtain insurance policies
directly from Blue Shield,and that the Contractholder,and not Blue Shield owes and is fully responsible to the
Producer for the Fee.
b. The Contractholder agrees to pay the Fee at the same time payment is made for the Premium for Blue Shield
coverages. '
C. The Contractholder will notify Blue Shield immediately if the Service Agreement between the Contractholder
and the Producer is terminated.
d. The Contractholder will be responsible for any and all tax reporting related to the payment of the Fee to the
Producer,including Form 1099s,if required.
3. Payments and Adjustments:
a. The Contractholder and the Producer have agreed that the amount of the Fee initially shall be 3.63% of the
monthly Premium amount per month.
b. The Contractholder will notify Blue Shield of any change to the Fee or the manner in which it is to be paid in
writing. For purposes of Blue Shield's duties and responsibilities under this Arrangement, any such change
will be effective the first day of the month following Blue Shield's receipt of such written notice of the change.
C. The Contractholder will notify Blue Shield of a producer of record change in writing.For purposes of Blue
Shield's duties and responsibilities under this Arrangement, any such change will be effective the first day of
C-15
PART VIII. GENERAL PROVISIONS
the month following Blue Shield's receipt of such written notice of the change.Following the change, Blue
Shield will remit the Fee to the new producer.
d. The parties acknowledge that any payment received by Blue Shield from the Contractholder will be applied
first to Premiums due to Blue Shield, and any amount in addition to such Premiums to payment of the Fee.
The Contractholder's failure to pay the Fee through Blue Shield will not subject the Contractholder to
termination of any Blue Shield coverages for non-payment of Premium.
e. The Contractholder acknowledges and agrees that Blue Shield may deposit the Fee into a general account that
may collect interest.Blue Shield may retain any interest or investment income on funds held in the account.
f. The Contractholder acknowledges and agrees that its Blue Shield coverages may,if otherwise eligible,be taken
into account in the calculation of any bonus program offered by Blue Shield to the Producer.
4. Term and Termination:
a. This Pass-Through Arrangement will automatically terminate as of the effective date of the termination of the
Contractholder's Blue Shield coverages.
b. The Contractholder may terminate this Arrangement at any time by providing written notice to Blue Shield.
Such termination will be effective the first day of the month following Blue Shield's receipt of the notice of
termination.
C. Blue Shield may terminate this Arrangement by providing no less than sixty(60)days'prior written notice to
the Contractholder.
a. The Contractholder and the Producer have agreed that the amount of the Fee initially shall be 3.63% of the
monthly Premium amount per month.
C-16
PART IX. CONTRACTHOLDER RESPONSIBILITY FOR DISTRIBUTION AND
NOTIFICATION REQUIREMENTS
The Contractholder has various distribution of notices and Member materials and other notification requirements under this
Group Health Service Contract. Some of the major Contractholder distribution and notification requirements are summarized
below;however,this is a summary only and is not to be construed as an all-inclusive list.
A. Obtaining Declinations or Waivers of Coverage
All eligible Employees will be offered health benefits coverage during the initial and subsequent enrollment periods. If
an Employee elects to decline or waive coverage, the Employer is responsible for obtaining the Employees signed
acknowledgment of receipt of an explicit written notice in bold type specifying that failure to elect coverage during the
Open Enrollment Period permits the Plan to impose an exclusion from coverage for a period of 12 months, or at the
Employer's next Open Enrollment Period, whichever is earlier, unless the Employee meets the criteria specified in
paragraph 1.of the definition of Late Enrollee as set forth in the EOC.
B. Distribution of Summary of Benefits and Coverage(SBC)
A summary of benefits and coverage (SBC)will be issued by the Plan for all eligible Employees and Dependents. The
Employer is solely responsible for the timely distribution of a complete SBC for each benefit plan offered.The Employer
will distribute the SBCs free of charge to Members and prospective Members as required by applicable federal law and
regulations.
The Employer shall distribute the SBCs in a manner which complies with applicable federal law and regulations. If the
Employer does not distribute paper SBCs,then the Employer will ensure that any alternative or electronic distribution
method used complies with applicable federal requirements.
If a material modification is made to the Employer's group health plan that impacts the SBC, other than at the time of
renewal, then notice of the material change, as provided by Blue Shield, will be distributed by the Employer to the
Subscriber and any Dependents no later than sixty (60) days prior to the date on which the modification will become
effective.The notice shall be distributed in a manner that complies with applicable federal requirements.
In the event that the Employer fails to distribute SBCs to Members or prospective Members as required herein, Blue
Shield will, after notice to the Employer, distribute SBCs as necessary to comply with applicable federal statutes and
regulations.In such case,the Employer agrees to reimburse Blue Shield for the reasonable costs incurred by Blue Shield
to generate and distribute the SBCs.
C. Distribution of Member ID Cards and EOC Booklets
1. Member ID Cards
Membership identification cards will be issued by the Plan for all Subscribers and will either be sent to the
Contractholder for distribution to the Subscribers, or sent directly to the Subscribers, depending on the
Contractholder's instructions.
2. EOC Booklets
An EOC which summarizes the Benefits of this Contract and how to obtain covered Services will be issued by the
Plan for all Subscribers. The Plan will send the EOC to the Contractholder, and,the Contractholder is responsible
for distributing the EOC to Subscribers whether in printed,hardcopy or electronic form.
EOCs will be provided to the Contractholder in electronic form(such as by Compact Disk(CD)or posted on Blue
Shield's employer website) or in paper hard copy form. If Contractholder receives the EOC in electronic form,
Contractholder is not authorized to modify or alter in any way the text or the formatting of the electronic EOC file.
Blue Shield assumes no responsibility for any changes in text or formatting that may occur in the EOC after it is
provided to Contractholder. If Contractholder receives the EOC in hard copy form, Contractholder will notify
Subscribers that printed hard copies of the EOC are available and will promptly distribute to Subscribers.
C-17
PART IX. CONTRACTHOLDER RESPONSIBILITY FOR DISTRIBUTION AND
NOTIFICATION REQUIREMENTS
Contractholder may ensure electronic distribution of the EOC to Subscribers by one of the following methods: (1)
by posting the EOC in a read-only format on an intranet site which is accessed by Employees of Contractholder;(2)
by emailing the EOC directly to Subscribers; or(3) by providing Subscribers with Blue Shield's instructions for
accessing the EOC from the Blue Shield website.
If Contractholder posts the electronic EOC on its intranet site,it shall do so in such a way so as to permit Employees
of Contractholder to download and print a complete and accurate copy of the EOC. Contractholder will notify
Employees enrolled with Blue Shield that the EOC for their plan is available to review,download and print from
Contractholder's intranet site,and will provide Subscribers with reasonable and appropriate instructions by which
to access and print the document from its intranet site.
Contractholder will provide a hard copy ofthe EOC to an Employee upon request.IfBlue Shield receives an inquiry
from an Employee of the Contractholder regarding obtaining a copy of the EOC, Blue Shield will refer that
individual to Contractholder's human resources benefits staff with instructions that a copy of the EOC is available
from Contractholder on request.Contractholder has the option to request a supply of hard copies of the EOC in an
amount not to exceed 10%of the total subscriber count at no additional charge.
In the event Blue Shield reasonably concludes that Contractholder is either using the electronic EOC in a matter not
permitted by this Agreement or is not providing Subscribers with access to the EOC in accordance herewith,then
Blue Shield will print copies of the EOC,and Contractholder will cooperate with Blue Shield to ensure that printed
copies of the EOC are timely provided to all Employees of Contractholder enrolled with Blue Shield.Contractholder
agrees to reimburse Blue Shield for the reasonable cost of printing and delivering the EOC documents.
D. Notice of Cancellation for Nonpayment of Premiums and Grace Period or Notice of Cancellation,Rescission or
Nonrenewal
Upon receipt of a Notice of Cancellation for Nonpayment of Premiums and Grace Period or a Notice of Cancellation,
Rescission or Nonrenewal from the Plan, the Employer shall promptly send any such Notice to each subscriber in a
manner which complies with applicable law.
E. Notification of COBRA and Cal-COBRA Coverage Option and Other COBRA/Cal-COBRA Notices
The following provisions are applicable only when the Contractholder is subject to Title X.of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA)as amended or the California Continuation Benefits Replacement Act(Cal-
COBRA). See the Continuation of Group Coverage and Extension of Benefits sections of the EOC for additional
information.
1. COBRA
Blue Shield is not the plan administrator or plan sponsor, as those terns are defined by ERISA, for any purpose,
including but not limited to COBRA, and has no responsibility for the Contractholder's COBRA administration
obligations
To the extent required by COBRA,and upon timely receipt of Dues and proper enrollment forms,Blue Shield will
continue the group coverage to qualified beneficiaries after the period that their coverage would normally terminate
under the Contract.
Blue Shield will not be responsible for determining whether a Subscriber or Dependent is eligible to receive
continuation coverage;such determination is based on the requirements of COBRA and the procedures established
by the Contractholder or its COBRA administrator.
If the Contractholder or any Subscriber or Dependent fails to meet its obligations under the Contract and COBRA,
Blue Shield shall not be liable for any claims of the Subscriber or Dependent after his/her termination of coverage,
except as expressly provided in other applicable provisions of the Contract.
C-18
PART IX. CONTRACTHOLDER RESPONSIBILITY FOR DISTRIBUTION AND
NOTIFICATION REQUIREMENTS
The Contractholder is solely responsible for all aspects of the administration of COBRA and any amendments with
respect to the group health coverage provided by this Contract.The obligations of the Contractholder in the event
that federal continuation of coverage requirements of COBRA apply to the Contractholder,include the following:
a. Contractholder or its COBRA administrator will complete and timely provide all notices and enrollment forms
to all eligible Subscribers and Dependents (including the initial notice of COBRA rights) required under
COBRA.
b. Contractholder or its COBRA administrator will establish procedures to verify eligibility for COBRA coverage
and receive COBRA election forms from Qualified Beneficiaries.
C. The Contractholder will notify its COBRA administrator(or the Plan administrator if the Contractholder does
not have a COBRA administrator)of the Subscriber's death,termination,or reduction of hours of employment,
or of the Subscriber's Medicare entitlement,orthe Employer's(Contractholder's)filing for reorganization under
Title XI,United States Code.
d. Contractholder or its COBRA administrator will establish a determination date upon which applicable COBRA
rates may be annually changed and determine the applicable premium amount for qualified COBRA
beneficiaries in accordance with its Contract with Blue Shield,adding the 2%administrative fee permitted by
COBRA.
C. Contractholder or its COBRA administrator will bill and collect premiums from COBRA Qualified
Beneficiaries,and provide timely notification of nonpayment of COBRA continuation coverage premiums,per
the terms of the Contract and COBRA.
f. Contractholder or its COBRA administrator will remit premiums to Blue Shield on behalf of the COBRA
qualified beneficiary until Blue Shield receives notice from the Contractholder that such beneficiary is no
longer entitled to COBRA coverage.
g. Contractholder or its COBRA administrator will provide notification of continuation of coverage rights to the
extent required by COBRA or any other federal or state laws as applicable, on termination of COBRA
coverage. The Contractholder or its COBRA administrator is responsible for notifying COBRA enrollees of
their right to possibly continue coverage under Cal-COBRA at least 90 calendar days before their COBRA
coverage will end.
h. Contractholder or its COBRA administrator will inform eligible Subscribers and Dependents of changes in the
COBRA law as they occur,including an explanation of the impact of these changes upon COBRA coverage.
i. The Contractholder agrees to assume responsibility for any and all COBRA violations resulting from the failure
of the Contractholder or its COBRA administrator to perform its COBRA administration responsibilities.
2. Cal-COBRA
Contractholders subject to the California Continuation Benefits Replacement Act(Cal-COBRA)are responsible for
notifying Blue Shield in writing within 30 days when the Contractholder becomes subject to Section 4980B of the
United States Internal Revenue Code or Chapter 18 of the Employee Retirement Income Security Act,29 U.S.C.
Section 1161 et seq.
Contractholders subject to the California Continuation Benefits Replacement Act(Cal-COBRA)are responsible for
notifying Blue Shield in writing of the Subscriber's termination or reduction in hours of employment within 30 days
of the Qualifying Event.
C-19
EVIDENCE OF COVERAGE AND DISCLOSURE FORM
An EOC booklet and any.applicable Supplements will be issued by Blue Shield for all Subscribers covered under this Group
Health Service Contract.The following pages contain the exact provisions of this EOC and any applicable Supplements and
are included as part of this Contract.
Note: In the EOC,references to"you'or"your"shall mean the eligible Subscriber and/or Dependent of this Plan.References
to"we"or"us"shall mean the Plan and/or Blue Shield of California.
C-20
J
City of Palm Springs Police and Fire
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Blue Shield of California
Evidence of Coverage and Disclosure Form
City of Palm Springs Police and Fire Custom PPO - Actives
PLEASE READ THE FOLLOWING IMPORTANT NOTICES ABOUT THIS
HEALTH PLAN
This Evidence of Coverage and Disclosure Form (EOC) constitutes only a summary of the Health Plan.
The health plan contract must be consulted to determine the exact terms and conditions of coverage.
Notice About This Group Health Plan: Blue Shield makes this Health Plan available to Employees
through a contract with the Employer.The Group Health Service Contract includes the terms in this EOC,
as well as other terms. A copy of the Contract is available upon request. A Summary of Benefits is pro-
vided with, and is incorporated as part of, the EOC. The Summary of Benefits sets forth the Member's
share-of-cost for Covered Services under the benefit Plan.
Please read this EOC carefully and completely to understand which services are Covered Services, and
the limitations and exclusions that apply to the Plan. Pay particular attention to those sections of the EOC
that apply to any special health care needs.
For questions about this Plan, please contact Blue Shield Customer Service at the address or telephone
number provided on the back page of this EOC.
Notice About Plan Benefits: No Member has the right to receive Benefits for services or supplies fur-
nished following termination of coverage, except as specifically provided under the Extension of Bene-
fits provision, and when applicable, the Continuation of Group Coverage provision in this EOC.
Benefits are available only for services and supplies furnished during the term this Health Plan is in effect
and while the individual claiming Benefits is actually covered by this Group Contract.
Benefits may be modified during the term as specifically provided under the terms of this EOC,the Group
Contract or upon renewal.If Benefits are modified,the revised Benefits (including any reduction in Bene-
fits or the elimination of Benefits) apply for services or supplies furnished on or after the effective date of
modification. There is no vested right to receive the Benefits of this Plan.
Notice About Reproductive Health Services: Some hospitals and other providers do not provide one or
more of the following services that may be covered under your Plan Contract and that you or your family
member might need: family planning; contraceptive services, including emergency contraception; steril-
ization, including tuba] ligation at the time of labor and delivery; Infertility treatments; or abortion. You
should obtain more information before you enroll. Call your prospective doctor, medical group, indepen-
dent practice association, or clinic, or call the health plan at Blue Shield's Customer Service telephone
number provided on the back page of this EOC to ensure that you can obtain the health care services that
you need.
Notice About Contracted Providers: Blue Shield contracts with Hospitals and Physicians to provide
services to Members for specified rates. This contractual arrangement may include incentives to manage
all services provided to Members in an appropriate manner consistent with the Contract. To learn more
about this payment system, contact Customer Service.
3
Notice About Health Information Exchange Participation: Blue Shield participates in the Manifest
MedEx Health Information Exchange("HIE")making its Members' health information available to Man-
ifest Medex for access by their authorized health care providers. Manifest Medex is an independent, not-
for-profit organization that maintains a statewide database of electronic patient records that includes health
information contributed by doctors, health care facilities, health care service plans, and health insurance
companies. Authorized health care providers (including doctors, nurses, and hospitals) may securely ac-
cess their patients' health information through the Manifest Medex HIE to support the provision of safe,
high-quality care.
Manifest Medex respects Members' right to privacy and follows applicable state and federal privacy laws.
Manifest Medex uses advanced security systems and modern data encryption techniques to protect Mem-
bers' privacy and the security of their personal information. The Manifest Medex notice of privacy prac-
tices is posted on its website at www.manifestmedex.org.
Every Blue Shield Member has the right to direct Manifest Medex not to share their health information
with their health care providers. Although opting out of Manifest Medex may limit your health care
provider's ability to quickly access important health care information about you, a Member's health in-
surance or health plan benefit coverage will not be affected by an election to opt-out of Manifest Medex.
No doctor or hospital participating in Manifest Medex will deny medical care to a patient who chooses
not to participate in the Manifest MedexHIE.
Members who do not wish to have their healthcare information displayed in Manifest Medex, should fill
out the online form at ,"vw.manifestmedex.org/opt-out or call Manifest Medex at (888) 510-7142.
4
Blue Shield of California
Subscriber Bill of Rights
As a Blue Shield Subscriber, you have the right to:
1) Receive considerate and courteous care,with informed decision before you receive treat-
respect for your right to personal privacy and ment.
dignity. 9) Receive preventive health,services.
2) Receive information about all health services 10)Know and understand your medical condi-
available to you, including a clear explana- tion, treatment plan, expected outcome, and
tion of how to obtain them. the effects these have on your daily living.
3) Receive information about your rights and re- 1 I)Have confidential health records, except,
sponsibilities. when disclosure is required by law or permit-
4) Receive information about your Health Plan, ted in writing by you. With adequate notice,
the services we offer you, the Physicians and you have the right to review your medical
other practitioners available to care for you. record with your Physician.
5) Have reasonable access to appropriate medi- 12)Communicate with and receive information
cal services. from Customer Service in a language you can
understand.
6) Participate actively with your Physician in
decisions regarding your medical care.To the 13)Know about any transfer to another Hospital,
including information tas en why the transfer
extent permitted by law, you also have the is necessary and any alternatives available.
right to refuse treatment.
7) A candid discussion of appropriate or Medi- 14)Be fully informed about the Blue Shield
cally Necessary treatment options for your grievance procedure and understand how to
condition,regardless of cost or benefit cover- use it without fear of interruption of health
care.
age.
8) Receive from your Physician an understand- 15)Voice complaints or grievances about the
ing of your medical condition and any pro- Health Plan or the care provided to you.
posed appropriate or Medically Necessary 16)Participate in establishing Public Policy of
treatment alternatives, including available the Blue Shield health Plan, as outlined in
success/outcomes information, regardless of your EOC.
cost or benefit coverage, so you can make an
5
Blue Shield of California
Subscriber Responsibilities
As a Blue Shield Subscriber, you have the responsibility to:
1) Carefully read all Blue Shield materials im- 8) Communicate openly with the Physician you
mediately after you are enrolled so you un- choose so you can develop a strong partner-
derstand how to use your Benefits and how to ship based on trust and cooperation.
minimize your out of pocket costs.Ask ques- 9) Offer suggestions to improve the Blue Shield
tions when necessary. You have the respon- Plan
sibility to follow the provisions of your Blue
Shield membership as explained in the EOC. 10)Help Blue Shield to maintain accurate and
current medical records by providing timely
2) Maintain your good health and prevent ill- information regarding changes in address,
ness by making positive health choices and family'status and other health plan coverage.
seeking appropriate care when it is needed.
11)Notify Blue Shield as soon as possible if you
3) Provide, to the extent possible, information are billed inappropriately or if you have any
that your Physician, and/or Blue Shield need to provide appropriate care for you. complaints.
12)Treat all Blue Shield personnel respectfully
active role in developing treatment goals witthh
4) Understand your health problems and take and courteously as partners in good health
your medical care provider, whenever possi- care.
ble. 13)Pay your Premiums, Copayments, Coinsur-
5) Follow the treatment plans and instructions ance and charges for non-covered services on
you and your Physician have agreed to and time.
consider the potential consequences if you 14)For all Mental Health and Substance Use Dis-
refuse to comply with treatment plans or rec- order Services, follow the treatment plans
ommendations. and instructions agreed to by you and the
6) Ask questions about your medical condition Mental Health Services Administrator
(MHSA)and obtain prior authorization as re-
and make certain that you understand the ex- quired.
planations and instructions you are given.
z) Make and keep medical appointments and in-
15)Follow the provisions of the Blue Shield Ben-
form your Physician ahead of time when you efits Management Program.
must cancel.
6
TABLE OF CONTENTS PAGE
Summaryof Benefits...........................................................................................................................................................................................9
TheBlue Shield PPO Health Plan.....................................................................................................................................................................17
Introduction to the Blue Shield of California Health Plan.................................................................................................................................17
Howto Use This Health Plan..................:..........................................................................................................................................................17
Choiceof Providers..................................................................................................................................................................................................................17
Continuity.of Care.....................................................................................................................................................................................................................18
SecondMedical Opinion Policy..............................................................................................................................................................................................18
Servicesfor Emergency Care..................................................................................................................................................................................................19
NurseHelp24/7 SM..................................................................................................................................................................................................................19
Retail-Based Health Clinics.....................................................................................................................................................................................................19
BlueShield Online....................................................................................................................................................................................................................19
HealthEducation and Health Promotion Services.................................................................................................................................................................20
TimelyAccess to Care.............................................................................................................................................................................................................20
Cost-Sharing..............................................................................................................................................................................................................................20
Submittinga Claim Form.............................................................................................................:...........................................................................................21
Out-of-Area Services.........................................................................................................................................................................................22
Overview...................................................................................................................................................................................................................................22
Inter-Plan Arrangements..........................................................................................................................................................:...............................................22
BlueCardProgram.....................................................................................................................................................................:.........::...................................22
BlueShield Global Core..........................................................................................................................................................................................................23
Care for Covered Urgent and Emergency Services Outside the BlueCard Service Area..................................................................................................23
SpecialCases:Value-Based Programs.............................................................................................................................................1.....................................23
UtilizationManagement.....................................................................................................................................................................................24
BenefitsManagement Program..........................................................................................................................................................................24
PriorAuthorization...................................................................................................................................................................................................................24
EmergencyAdmission Notification........................................................................................................................................................................................26
InpatientUtilization Management................................................................................................:.....................................................................................6....26
DischargePlanning...................................................................................................................................................................................................................26
CaseManagement.....................................................................................................................................................................................................................26
PalliativeCare Services.......................................................................................................................................................................................................6....26
Principal Benefits and Coverages(Covered Services)...............................................................:....................................................................6.26
AcupunctureBenefits...................................................................................................................................................:...........................................................27
AllergyTesting and Treatment Benefits........................................................................................................................................................................6......6.27
AmbulanceBenefits...........................................................................................................................................................................................6.....................27
AmbulatorySurgery Center Benefits......................................................................................................................................................................................27
BariatricSurgery Benefits......................................................................................................................................................................................................6.27
ChiropracticBenefits......................................................................................................................................................................:.........................................29
Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits..............................................................................................................29
DiabetesCare Benefits.....................................................................................................................................................................................6.......................30
DialysisBenefits...........................................................................................................................................................................................6...........................30
DurableMedical Equipment Benefits.....................................................................................................................................................................................31
EmergencyRoom Benefits......................................................................................................................................................................................................31
FamilyPlanning and Infertility Benefits.............................................................................................................................................................................6...31
HomeHealth Care Benefits.....................................................................................................................................................................................................32
Home Infusion and Home Injectable Therapy Benefits..........:.....................................................................................:...................................................6...32
HospiceProgram Benefits.........::....................................................................................................................................................................................6......633
HospitalBenefits(Facility Services).............................................................................................................................................................................6....6.6.634
Medical Treatment of the Teeth,Gums,or Jaw Joints and Jaw Bones Benefits................................................................................................................35
Mental Health and Substance Use Disorder Benefits..............................................................................................................................................6....6.6......36
OrthoticsBenefits.....................................................................................................................................................................................................................37
Outpatient X-ray,Pathology and Laboratory Benefits..........................................................................................................................................................37
PKU Related Formulas and Special Food Products Benefits...................................................................................................................6...........................38
PodiatricBenefits;..................................................................................................................:...................................................................................................38
Pregnancyand Maternity Care Benefits.......................................................................................................................................................6.........................38
PreventiveHealth Benefits...........................................P...............6...6...66......66...P.....................6—.........6 6....................................6.....—66—.........................3&
Professional(Physician)Benefits..........................................6.6666............................................6......6............................................66.......6..................................39
ProstheticAppliances Benefits......................................................................................................................................................................................6.........40
Radiological and Nuclear Imaging Benefits..........................................................................................................................................................................40
ReconstructiveSurgery Benefits.............................................................................................................................................................................................40
Rehabilitative and Habilitative Services Benefits(Physical,Occupational and Respiratory Therapy)............................................................................41
SkilledNursing Facility Benefits.....6-6..............................6.........P.................................6-6........66...................................6....6...........P...........................6.........41
Speech Therapy Benefits(Rehabilitative and Habilitative Services)...................................................................................................................................41
TransplantBenefits...............................................................................................................................................................................................................—Al
Principal Limitations,Exceptions,Exclusions and Reductions.........................................................................................................................42.
7
TABLE OF CONTENTS PAGE
GeneralExclusions and Limitations.......................................................................................................................................................................................42
MedicalNecessity Exclusion...................................................................................................................................................................................................45
Limitationfor Duplicate Coverage..........................................................................................................................................................................................45
Exceptionfor Other Coverage.................................................................................................................................................................................................46
ClaimsReview..........................................................................................................................................................................................................................46
Reductions—Thud Party Liability..........................................................................................................................................................................................46.
Coordinationof Benefits..........................................................................................................................................................................................................47
Conditionsof Coverage.....................................................................................................................................................................................48
Eligibilityand Enrollment........................................................................................................................................................................................................48
EffectiveDate of Coverage......................................................................................................................................................................................................48
Premiums(Dues)......................................................................................................................................................................................................................49
GracePeriod..............................................................................................................................................................................................................................49
PlanChanges.............................................................................................................................................................................................................................49
Renewalof the Group Health Service Contract.....................................................................................................................................................................49
Termination of Benefits(Cancellation and Rescission of Coverage)..................................................................................................................................49
Extensionof Benefits................................................................................................................................................................................................................51
GroupContinuation Coverage.................................................................................................................................................................................................52
GeneralProvisions.............................................................................................................................................................................................55
Liability of Subscribers in the Event ofNon-Payment by Blue Shield...............................................................................................................................55
RightofRecovery.....................................................................................................................................................................................................................55
NoLifetime Benefit Maximum...............................................................................................................................................................................................55
No Annual Dollar Limits on Essential Health Benefits........................................................................................................................................................55
IndependentContractors..........................................................................................................................................................................................................55
Non-Assignability.....................................................................................................................................................................................................................56
PlanInterpretation.....................................................................................................................................................................................................................56
PublicPolicy Participation Procedure.....................................................................................................................................................................................56
Confidentiality of Personal and Health Information..............................................................................................................................................................56
Accessto Information...............................................................................................................................................................................................................57
GrievanceProcess..............................................................................................................................................................................................57
MedicalServices.......................................................................................................................................................................................................................57
Mental Health and Substance Use Disorder Services...........................................................................................................................................................58
ExternalIndependent Medical Review...................................................................................................................................................................................58
Departmentof Managed Health Care Review.......................................................................................................................................................................59
CustomerService...............................................................................................................................................................................................59
Definitions..........................................................................................................................................................................................................60
OutpatientPrescription Drug Rider'...................................................................................................................................................................71
ContactingBlue Shield of California.................................................................................................................................................................80
8
blue �q, of california
City of Palm Springs Police and Fire
Effective January 1,2020
Summary of Benefits PPO Plan
City of Palm Springs Police and Fire Custom PPO - Actives
This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan.It
is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents care-
fully for details.
Medical 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 Blue Shield pays for
Covered Services under the Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is
met,as noted in the Benefits chart below. o
When using a Non-
When using a Par- Participating o
ticipating Provider3 Provider^
Calendar Year medical Deductible Individual coverage $0 $100 m a
Family coverage $0:individual $100:individual ti
0
$0: Family $300:Family
m
0
Calendar Year Out-of-Pocket Maximums _
An Out-of-Pocket Maximum is the most a Member will pay for Covered Services No Annual or Lifetime Dollar o
each Calendar Year.An exceptions are listed in the Notes section at the end
Y P Limit
of this Summary of Benefits. E
When using any combination Under this Plan there is no annual E
When using a Partici- of Participating3 or Non-Partic- or lifetime dollar limit on the `c
pating Provider3 ipating^Providers amount Blue Shield will pay for a
Covered Services. c
Individual coverage $500 $1,500 Q.
Family coverage $500:individual $1,500:individual m
a
c
$1,500: Family $4,500: Family
0
o
c
`0
`o
V
0
a
t
N
N
m
A44629 (01/20) 9 blueshieldca.com
Benefits" Your payment
When using a When using a
Participating CYD2 Non-Participating CYD2
Provider3 applies Provider° applies
Preventive Health Servicesr
Preventive Health Services $0 30%
California Prenatal Screening Program $0 $0
Physician services
Primary care office visit 10% 30%
Specialist care office visit 10% 30%
Physician home visit 10% 30%
Physician or surgeon services in an outpatient facility 10% 30%
Physician or surgeon services in an inpatient facility 10% 30%
Other professional services
Other practitioner office visit 10% 30%
Includes nurse practitioners, physician assistants,
and therapists.
Acupuncture services 10% 30%
Up to 20 visits per Member, per Calendar Year.
Chiropractic services 10% 307.
Up to 20 visits per Member, per Calendar Year.
Teladoc consultation $5/consult Not covered
Family planning
• Counseling,consulting, and education $0 30%
• Injectable contraceptive; diaphragm fitting, in-
trauterine device(IUD),implantable contracep- $0 30%
tive,and related procedure.
• Tuba[ligation $0 30%
• Vasectomy 10% 30%
Podiatric services 10% 30%
Pregnancy and maternity care'
Physician office visits:prenatal and postnatal 10% 30%
Physician services for pregnancy termination 10% 30%
Emergency services
Emergency room services $50/visit plus 10% $50/visit plus 10%
If admitted to the Hospital, this payment for emer-
gency room services does not apply. Instead, you
pay the Participating Provider payment under In-
patient facility services/Hospital services and stay.
Emergency room Physician services 10% 10%
10
Benefits" Your payment
When using a When using a
Participating CYD' Non-Participating CYD2
Provider3 applies Provider" applies
Urgent care center services 10% 30%
Ambulance services 10% 10%
This payment is for emergency or authorized transport.
Outpatient facility services
30%of up to
Ambulatory Surgery Center 10% $350/day
plus 100%of addi-
tional charges
30%of up to
Outpatient Department of a Hospital:surgery 10% $
plus 1000%0%day
of addi-
tional charges
Outpatient Department of a Hospital:treatment of ill- 30%of up to
ness or injury,radiation therapy,chemotherapy,and 10% tional$00%day
necessary supplies plus charges
Inpatient facility services
30%of up to
Hospital services and stay 10% $600/day
plus 100%of addi-
tional charges
Transplant services
This payment is for all covered transplants except
tissue and kidney. For tissue and kidney transplant
services,the payment forinpatient facility services/
Hospital services and stay applies.
• Special transplant facility inpatient services 10% Not covered
• Physician inpatient services 10% Not covered
Bariatric surgery services,designated California counties
This payment is for bariatric surgery services forresidents
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 pro-
vided on an outpatient basis, the outpatient facility ser-
vices and Outpatient Physician services payments ap-
ply.
Inpatient facility services 10% Not covered
Outpatient facility services 10% Not covered
Physician services 10% Not covered
11
Benefitsd Your payment
When using a When using a
Participating CYD2 Non-Participating CYD2
Provider3 applies Provider° applies
Diagnostic x-ray, Imaging, pathology, and laboratory
services
This payment is for Covered Services that are diagnos-
tic, non-Preventive Health Services, and diagnostic ra-
diological procedures, such as CT scans, MRIs, MRAs,
and PET scans. For the payments for Covered Services
that are considered Preventive Health Services, see
Preventive Health Services.
Laboratory services
Includes diagnostic Papanicolaou(Pap) test.
• Laboratory center 1097, 307. r
30%of up to
• Outpatient Department of a Hospital 10% $350/day r
plus 100%of addi-
tional charges
X-ray and imaging services
Includes diagnostic mammography.
• Outpatient radiology center 10% 30% r
30%of up to
• Outpatient Department of a Hospital 10% $350/day r
plus 100%of addi-
tional charges
Other outpatient diagnostic testing
Testing to diagnose illness or injury such as vestibu-
lar function tests, EKG, ECG, cardiac monitoring,
non-invasive vascular studies,sleep medicine test-
ing, muscle and range of motion tests, EEG, and
EMG.
• Office location 10% 30% r
30%of up to
• Outpatient Department of a Hospital 10% $350/day r
plus 100%of addi-
tional charges
Radiological and nuclear imaging services
• Outpatient radiology center 10% 30% r
30%of up to
• Outpatient Department of a Hospital 10% $350/day r
plus 100%of addi-
tional charges
Rehabilitative and Habilitative Services
Includes Physical Therapy, Occupational Therapy,Res-
piratory Therapy, and Speech Therapy services.
Office location 10% 30% r
12
Benefrfs6 Your payment
When using a When using a
Participating CYD2 Non-Participating CYD2
Providers applies Provider4 applies
30%of up to
Outpatient Department of a Hospital 10% $350/day
plus 100%of addi-
tional charges
Durable medical equipment(DME)
DME 10% 30%
Breast pump $0 Not covered
Orthotic equipment and devices 10% 30%
Prosthetic equipment and devices 10% 30%
Home health care services 10% 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 sup-
plies.
Home infusion and home Injectable therapy services
Home infusion agency services 10% Not covered
Includes home infusion drugs and medical supplies.
Home visits by an infusion nurse 10% Not covered
Hemophilia home infusion services 10% Not covered
Includes blood factorproducts.
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 ap-
plicable Deductible period and days in different SNFs
during the Calendar Year.
Freestanding SNF 10% 10%
30%of up to
Hospital-based SNF 10%, $600/day
plus 100%of addi-
tional charges
Hospice program services $0 Not covered
Includes pre-Hospice consultation,routine home care,
24-hour continuous home care, short-term inpatient
care for pain and symptom management, and inpa-
tient respite care.
Other services and supplies
Diabetes care services
Devices,equipment,and supplies 10% 30%
13
Benefits' Your payment
When using a When using a
Participating CYD2 Non-Participating CYD2
Provider3 applies Provider' applies
Self-management training 10% 30%
30%of up to
Dialysis services 10% $350/day
plus 100%of addi-
tional charges
PKU product formulas and Special Food Products 10% 10%
Allergy serum billed separately from an office visit 10% 30%
Mental Health and Substance Use Disorder Benefits Your payment
Mental health and substance use disorder Benefits are When using a
provided through Blue Shield's Mental Health Service MHSA 2 When using a 2
Administrator(MHSA). Participating CYD2 MHSA Non-Part - CYD
Provider3 applies ipating Provider° applies
Outpatient services
Office visit,including Physician office visit 10% 30%
Other outpatient services, including intensive outpa-
tient care, electroconvulsive therapy, transcranial
magnetic stimulation, Behavioral Health Treatment $0 30%
for pervasive developmental disorder or autism in an
office setting,home,or other non-institutional facility
setting,and office-based opioid treatment
30%of up to
Partial Hospitalization Program $0 $350/day V
plus 100%of addi-
tional charges
Psychological Testing $0 30%
Inpatient services
Physician inpatient services 10% 30%
30%of up to
Hospital services 10% $600/day 0
plus 100%of addi-
tional charges
30%of up to
Residential Care 10% $600/day
plus 100%of addi-
tional charges
14
Prior Authorization
The following are some frequently-utilized Benefits that require prior authorization:
• Radiological and nuclear imaging services Hospice program services
• Outpatient mental health services,except office
visits
• Inpatient facility services
Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Notes
1 Evidence of Coverage(EOC):
The Evidence of Coverage (EOC) describes the Benefits,limitations,and exclusions that apply to coverage under this
Plan. Please review the EOC for mare details of coverage outlined in this Summary of Benefits.You can request a copy
of the EOC at any time.
Capitalized terms are defined in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of
Benefits.
2 Calendar Year Deductible(CYD):
Calendar Year Deductible explained. A Deductible is the amount you pay each Calendar Year before Blue Shield
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 (v) in the Benefits chart above.
Covered Services not subiecf to the Calendar Year medical Deductible.Some Covered Services received from Par-
ticipating Providers are paid by Blue Shield before you meet any Calendar Year medical Deductible.These Covered
Services do not have a check mark(v) next to them in the"CYD applies" column in the Benefits chart above.
This Plan has a separate Participating Provider Deductible and Non-Participating Provider 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 priorto the Family meeting the Family De-
ductible within a Calendar Year.
3 Using Participating Providers:
Participating Providers have a contract to provide health care services to Members. When you receive Covered Ser-
vices 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 EOC. In addition:
. Coinsurance is calculated from the Allowable Amount or Benefit maximum,whichever is less.
4 Using Non-Padcipating Providers:
Non-Porticiooting 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
• any charges above the Allowable Amount,or
• any charges above the stated dollar amount,which is the Benefit maximum.
"Allowable Amount"is defined in the EOC. In addition:
Coinsurance is calculated from the Allowable Amount or Benefit maximum,whichever is less.
15
Notes
Charges above the Allowable Amount or Benefit maximum do not count towards the Out-of-Pocket Maxi-
mum,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):
Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges above a Benefit maxi-
mum.
Essential health benefits count towards the OOPM.
Any Deductibles count towards the OOPM.Any amounts you pay that count towards the medical Calendar Year De-
ductible also count towards the Calendar Year Out-of-Pocket Maximum.
This Plan has a Participating Provider OOPM as well as a combined Participating Provider and Non-Participating
Provider OOPM.This means that any amounts you pay towards your Participating Provider OOPM also count towards
your combined Participating 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 indi-
vidual 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 Copayment in addition to an allergy serum Copayment 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 by a Participating Provider. 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 State and Federal requirements.
16
tion to verify whether the provider chosen is a Par-
The Blue Shield PPO Health Plan ticipating Provider or an MHSA Participating
Provider prior to obtaining coverage.
Introduction to the Blue Shield of Call Customer Service or visit
California Health Plan www.blueshieldca.com to determine whether a
provider is a Participating Provider. Call the
This Blue Shield of California (Blue Shield) Evi- MHSA to determine if a provider is an MHSA Par-
dence of Coverage and Disclosure Form (EOC) ticipating Provider. See the sections below and the
describes the health care coverage that is provided Summary of Benefits for more details. See the
under the Group Health Service Contract between Out-of-Area Services section for services outside
Blue Shield and the Contractholder(Employer).A of California.
Summary of Benefits is provided with, and is in- Blue Shield Participating Providers
corporated as part of,this EOC.
Please read both this EOC and Summary of Bene- Blue Shield Participating Providers include pri-
fits carefully. Together they explain which ser- mary care Physicians, specialists, Hospitals, and
vices are covered and which are excluded. They Alternate Care Services Providers that have a con-
also contain information about Member responsi- tractual relationship with Blue Shield. Participat-
bilities, such as payment of Copayments, Coinsur- ing Providers are listed in the Participating
ance and Deductibles and obtaining prior autho- Provider directory.
rization for certain services (see the Benefits Man- Participating Providers agree to accept Blue
agement Program section). Shield's payment, plus the Member's payment of
Capitalized terms in this EOC have special mean- any applicable Deductibles,Copayments,Coinsur-
ing. Please see the Definitions section to under- ance or amounts in excess of specified Benefit
maximums as payment-in-full for Covered Ser-
stand these terms. Please contact Blue Shield with
questions about Benefits. Contact information can vices, except as provided under the Exception for
be found on the last page of this EOC. Other Coverage and the Reductions—Third Party
Liability sections. This is not true of Non-Partici-
How to Use This Health Plan gating Providers.
PLEASE READ THE FOLLOWING INFORMA- If a Member receives services from a Non-Partici-
pating Provider, Blue Shield's payment for that
OR WHAT GROUP OF PROVIDERS HEALTH service may be substantially less than the amount
CARE MAY BE OBTAINED. billed. The Subscriber is responsible for the differ-
ence between the amount Blue Shield pays and the
Choice of Providers amount billed by the Non-Participating Provider.
This Blue Shield Health Plan is designed for Mem- If a Member receives services at a facility that is a
bers to obtain services from Blue Shield Participat- Participating Provider, Blue Shield's payment for
ing Providers and MHSA Participating Providers. Covered Services provided by a health profes-
However, Members may choose to seek services sional at the Participating Provider facility will be
from Non-Participating Providers for most ser- paid at the Participating Provider level of Benefits,
vices. Covered Services obtained from Non-Par- whether the health professional is a Participating
ticipating Providers will usually result in a higher Provider orNon-Participating Provider.The Mem-
share of cost for the Member. Some services are ber's share of cost will not exceed the Copayment
not covered unless rendered by a Participating or Coinsurance due to a participating Provider un-
Provider or MHSA Participating Provider. der similar circumstances.
Please be aware that a provider's status as a Partic- Some services are covered only if rendered by a
ipating Provider or an MHSA Participating Participating Provider. In these instances, using a
Provider may change. It is the Member's obliga- Non-Participating Provider could result in a higher
17
share of cost to the Member or no payment by Blue will not exceed the Copayment or Coinsurance due
Shield for the services received. to an MHSA Participating Provider under similar
Payment for Emergency Services rendered by a circumstances.
Physician or Hospital that is not a Participating Continuity of Care
Provider will be based on Blue Shield's Allowable
Amount and will be paid at the Participating level Continuity of care with a Non-Participating
of Benefits. The Member is responsible for notify- Provider is available for the following Members:
ing Blue Shield within 24 hours, or as soon as rea- for Members who are currently seeing a provider
sonably possible following medical stabilization who is no longer in the Blue Shield; or for newly-
of the emergency condition. covered Members whose previous health plan was
Please call Customer Service or visit withdrawn from the market.
www.blueshieldca.com to determine whether a Members who meet the eligibility requirements
provider is a Participating Provider. listed above may request continuity of care if they
MHSA Participating Providers are being treated for acute conditions, serious
chronic conditions, pregnancies (including imme-
For Mental Health Services and Substance Use diate postpartum care), or terminal illness. Conti-
Disorder Services,Blue Shield has contracted with nuity of care may also be requested for children
a Mental Health Service Administrator (MHSA). who are up to 36 months old, or for Members who
The MHSA is a specialized health care service have received authorization from a now-termi-
plan licensed by the California Department of nated provider for surgery or another procedure as
Managed Health Care, and will underwrite and de- part of a documented course of treatment.
liver Blue Shield's Mental Health Services and
Substance Use Disorder Services through a sepa- w request continuity of care, visit
rate network of MHSA Participating Providers. of Care Application. B and fill out the Continuity
of Care Application. Blue Shield will review the
MHSA Participating Providers are those providers request. The Non-Participating Provider must
who participate in the MHSA network and have agree to accept Blue Shield's Allowable Amount
contracted with the MHSA to provide Mental as payment in full for ongoing care. When autho-
Health and Substance Use Disorder Services to rized, the Member may continue to see the Non-
Blue Shield Members.A Blue Shield Participating Participating Provider for up to 12 months at the
Provider may not be an MHSA Participating Participating Provider rate.
Provider. It is the Member's responsibility to en-
sure that the provider selected for Mental Health Second Medical Opinion Policy
and Substance Use Disorder Services is an MHSA Members who have questions about their diag-
Participating Provider. MHSA Participating noses, or believe that additional information con-
Providers are identified in the Blue Shield Behav- cerning their condition would be helpful in deter-
ioral Health Provider Directory. Additionally, mining the most appropriate plan of treatment,
Members may contact the MHSA directly by call- may make an appointment with another Physician
ing 1-877-263-9952. for a second medical opinion. The Member's at-
If a Member receives services at a facility that is tending Physician may also offer a referral to an-
an MHSA Participating Provider, MHSA's pay- other Physician for a second opinion.
ment for Mental Health and Substance Use Disor- The second opinion visit is subject to the applica-
der Services provided by a health professional at ble Copayment, Coinsurance, Calendar Year De-
the MHSA Participating Provider facility will be ductible and all Plan Contract Benefit limitations
paid at the MHSA Participating Provider level of and exclusions.
Benefits, whether the health professional is an State law requires that health plans disclose to
MHSA Participating Provider or MHSA Non-Par-
ticipating Provider. The Member's share of cost Members, upon request,the timelines for respond-
ing to a request for a second medical opinion. To
18
request a copy of these timelines,you may call the In the case of a medical emergency, call 911. For
Customer Service Department at the number pro- personalized medical advice, Members should
vided on the back page of this EOC. consult with their physicians.
Services for Emergency Care Life Referrals 24/7
The Benefits of this Plan will be provided for The Life Referrals 24/7 program offers Members
Emergency Services received anywhere in the access to professional counselors 24 hours a day,
world for the emergency care of an illness or in- seven days a week for psychosocial support ser-
jury. vices. Professional Counselors can provide confi-
For Emergency Services from either a Participat- dential telephone support, including concerns
ing Provider or a Non-Participating Provider, the about:
Member is only responsible for the applicable De-
ductible, Copayment or Coinsurance as shown in
the Summary of Benefits, and is not responsible 2) consultations; and
for any Allowable Amount Blue Shield is obli- 3) referrals for health and psychosocial issues.
gated to pay.
Members who reasonably believe that they have an Members may obtain this service by calling the
Emergency Medical Condition which requires an toll-free telephone number at 1-800-985-2405.
emergency response are encouraged to use the There is no charge for this confidential service.
"911" emergency response system (where avail-
able)or seek immediate care from the nearest Hos- Retail-Based Health Clinics
pital. For the lowest out-of-pocket expenses, cov- Retail-based health clinics are outpatient facilities,
ered non-Emergency Services or emergency room usually attached or adjacent to retail stores and
follow-up services (e.g., suture removal, wound pharmacies that provide limited, basic medical
check, etc.) should be received in a Participating treatment for minor health issues. They are staffed
Provider's office. by nurse practitioners, under the direction of a
su physician, and offer services on a walk-in basis.
NurseHelp 24/7 Covered Services received from retail-based
The NurseHelp 24/7 program offers Members ac- health clinics will be paid on the same basis and at
cess to registered nurses 24 hours a day,seven days the same Benefit levels as other Covered Services
a week. Registered nurses can provide assistance shown in the Summary of Benefits. Retail-based
in answering many health-related questions, in- health clinics may be found in the Participating
cluding concerns about: Provider directory or the online provider directory
located at www.blueshieldca.com. See the Blue
1) symptoms the patient is experiencing; Shield Participating Providers section for infor-
2) minor illnesses and injuries; mation on the advantages of choosing a Participat-
3) chronic conditions; , ing Provider.
4) medical tests and medications; and Blue Shield Online
5) preventive care. Blue Shield's Internet site is located at
Members may obtain this service by calling the www.blueshieldca.com. Members with Internet
toll-free telephone number at 1-877-304-0504 or access may view and download healthcare infor-
by participating in a live online chat at mation.
www.blueshieldca.com.There is no charge for this
confidential service.
19
Health Education and Health Promotion Cost-Sharing
Services The Summary of Benefits provides the Member's
Blue Shield offers,a variety of health education Copayment, Coinsurance, Calendar Year De-
and health promotion services including, but not ductible and Calendar Year Out-of-Pocket Maxi-
limited to,a prenatal health education program, in- mum amounts.
teractive online healthy lifestyle programs, and a Calendar Year Medical Deductible
monthly e-newsletter.
The Calendar Year Medical Deductible is the
Timely Access to Care amount an individual or a Family must pay for
Blue Shield provides the following guidelines to Covered Services each year before Blue Shield be-
provide Members timely access to care from Par- gins payment in accordance with this
ticipating Providers. EOC.The Calendar Year Medical Deductible does
not apply to all plans. When applied, this De-
Urgent Care Access to Care ductible accrues to the Calendar Year Out-of-
For Services that don't Within 48 hours Pocket Maximum. Information specific to the
need prior approval Member's Plan is provided in the Summary of
For Services that do need Within 96 hours Benefits.
prior approval The Summary of Benefits indicates whether or not
Non-Urgent Care Access to Care the Calendar Year Medical Deductible applies to a
Primary care appoint-
Within 10 business particular Covered Service.
ment days There are individual and Family Calendar Year
Specialist appointment Within 15 business Medical Deductible amounts. The individual
days Medical Deductible applies when an individual is
covered by the plan. The Family Medical De-
Appointment with a men- Within 10 business ductible applies when a Family is covered by the
tal health provider (who days plan.
is not a physician)
Appointment for other Within 15 business There is also an individual Medical Deductible
within the Family Medical Deductible.This means
services to diagnose or days Blue Shield will pay Benefits for any Family mem-
treat a health condition ber who meets the individual Medical Deductible
Telephone Inquiries Access to Care amount before the Family Medical Deductible is
Access to a health profes- 24 hours/day, met.
sional for telephone 7 days/week Once the respective Deductible is reached, Cov-
screenings ered Services are paid at the Allowable Amount,
Note: For availability of interpreter services at the less any applicable Copayment or Coinsurance,for
time of the Member's appointment, consult the the remainder of the Calendar Year.
Participating Provider directory available at For Covered Services received from Non-Partici-
www.blueshieldca.com or by calling Customer pating Providers, excluding Covered Services pro-
Service at the telephone number provided on the vided at a Participating Provider facility by a
back page of this EOC. More information for in- health professional who is a Non-Participating
terpreter services is located in the Notice of the Provider, the Member is responsible for the appli-
Availability of Language Assistance Services sec- cable Copayment or Coinsurance and for amounts
tion of this EOC. billed in excess of Blue Shield's Allowable
Amount. Charges in excess of Blue Shield's Al-
lowable Amount do not accrue to the Calendar
Year Medical Deductible.
20
Calendar Year Out of Pocket Maximum quired under this Health Plan within the same Cal-
The Calendar Year Out-of-Pocket Maximum is the endar Year:
highest Deductible, Copayment and Coinsurance 1) The Member was enrolled in a Health Plan
amount an individual or Family is required to pay sponsored by the Employer with a prior carrier
for designated Covered Services each year. If a during the same Calendar Year this Contract
benefit plan has any Calendar Year Medical De- becomes effective and the Member enrolls as
ductible, it will accumulate toward the applicable of the original effective date of coverage under
Calendar Year Out-of-Pocket Maximum. The this Contract;
Summary of Benefits indicates whether or not Co- z) The Member was enrolled under another Blue
payment and Coinsurance amounts for a particular Shield plan sponsored by the same Employer
Covered Service accrue to the Calendar Year Out- which is being replaced by this Health Plan;
of-Pocket Maximum.
T 3) The Member was enrolled under another Blue
There are individual and Family Calendar Year
Out-of-Pocket Maximum amounts for both Partic- Shield plan sponsored by the same Employer
and is transferring to this Health Plan during
ipating Providers and Non-Participating Providers. the Employer's Open Enrollment Period.
The individual Calendar Year Out-of-Pocket Max-
imum applies when an individual is covered by the This Prior Carrier Deductible Credit provision ap-
plan. The Family Calendar Year Out-of-Pocket plies only in the circumstances described above.
Maximum applies when a Family is covered by the
plan. Submitting a Claim Form
There is also an individual Out-of-Pocket Maxi- Participating Providers submit claims for payment
mum within the Family Calendar Year Out-of- directly to Blue Shield, however there may be
Pocket Maximum. This means that any Family times when Members and Non-Participating
member who meets the individual Out-of-Pocket Providers need to submit claims.
Maximum will receive 100%Benefits for Covered Except in the case of Emergency Services, Blue
Services, before the Family Out-of-Pocket Maxi- Shield will pay Members directly for services ren-
mum is met. dered by a Non-Participating Provider. Claims for
The Summary of Benefits provides the Calendar payment must be submitted to Blue Shield within
Year Out-of-Pocket Maximum amounts for Partic- one year after the month services were provided.
ipating Providers and Non-Participating Providers Blue Shield will notify the Member of its determi-
at both the individual and Family levels. When the nation within 30 days after receipt of the claim.
respective maximum is reached, Covered Services To submit a claim for payment, send a copy of the
will be paid by Blue Shield at 100%of the Allow- itemized bill, along with a completed Blue Shield
able Amount or contracted rate for the remainder claim form to the Blue Shield address listed on the
of the Calendar Year. last page of this EOC.
Charges for services that are not covered, charges Claim forms are available online at
in excess of the Allowable Amount or contracted www.blueshieldca.com or Members may call Blue
rate, do not accrue to the Calendar Year Out-of- Shield Customer Service to obtain a form. At a
Pocket Maximum and continue to be the Mem- minimum,each claim submission must contain the
ber's responsibility after the Calendar Year Out- Subscriber's name, home address, Group Contract
of-Pocket Maximum is reached. number, Subscriber number, a copy of the
Prior Carrier Deductible Credit provider's billing showing the services rendered,
If a Member satisfies all or part of a medical De- dates of treatment and the patient's name.
ductible under a Health Plan sponsored by the Em- Members should submit their claims for all Cov-
ployer under any of the following circumstances, ered Services even if the Calendar Year Deductible
that amount will be applied to the Deductible re- has not been met. Blue Shield will keep track of
21
the Deductible for the Member. Blue Shield also Evidence of Coverage. However, the Host Blue is
provides an Explanation of Benefits to describe responsible for contracting with and generally han-
how the claim was processed and to inform the dling all interactions with its participating health-
Member of any financial responsibility, care providers, including direct payment to the
provider.
Out-of-Area Services Whenever you receive Covered Services outside
of California, within the BlueCard Service Area,
Overview and the claim is processed through the BlueCard
Blue Shield has a variety of relationships with Program, your Member share of cost for these ser-
other Blue Cross and/or Blue Shield Licensees. vices, if not a flat dollar copayment, is calculated
Generally,these relationships are called Inter-Plan based on the lower of:
Arrangements and they work based on rules and 1) The billed charges for Covered Services; or
procedures issued by the Blue Cross Blue Shield 2) The negotiated price that the Host Blue makes
Association. Whenever you receive Covered Ser- available to Blue Shield.
vices outside of California, the claims for those
services may be processed through one of these In- Often, this negotiated price will be a simple dis-
ter-Plan Arrangements described below. count that reflects an actual price that the Host
When you access Covered Services outside of Cal- Blue pays to your healthcare provider. Sometimes,
ifornia, but within the United States,the Common- it is an estimated price that takes into account spe-
wealth of Puerto Rico, or the U. S. Virgin Islands cial arrangements with your healthcare provider or
(BlueCard® Service Area), you will receive the provider group that may include types of settle-
care from one of two kinds of providers. Partici- ments, incentive payments, and/or other credits or
pating providers contract with the local Blue Cross charges. Occasionally, it may be an average price,
and/or Blue Shield Licensee in that other geo- based on a discount that results in expected aver-
graphic area (Host Blue). Non-participating age savings for similar types of healthcare
providers don't contract with the Host Blue. Blue providers after taking into account the same types
Shield's payment practices for both kinds of of transactions as with an estimated price.
providers are described below and in the Choice of Estimated pricing and average pricing, going for-
Providers section of this EOC. ward, also take into account adjustments to correct
for over- or underestimation of modifications of
Inter-Plan Arrangements past pricing of claims as noted above. However,
Emergency Services such adjustments will not affect the price Blue
Shield used for your claim because these adjust-
Members who experience an Emergency Medical ments will not be applied retroactively to claims
Condition while traveling outside of California already paid.
should seek immediate care from the nearest Hos- To find participating BlueCard providers you can
pital. The Benefits of this plan will be provided call BlueCard Access® at 1-800-810-BLUE
anywhere in the world for treatment of an Emer-
(2583) or go online at www.bebs.com and select
gency Medical Condition. "Find a Doctor".
BlueCard Program Prior authorization may be required for non-emer-
Under the BlueCard® Program, benefits will be gency services. Please see the Benefits Manage-
ment Program section for additional information
provided for Covered Services received outside of
California, but within the BlueCard Service Area. on prior authorization and emergency admission
notification.
When you receive Covered Services within the ge-
ographic area served by a Host Blue, Blue Shield Non-participating Providers Outside of Cali-
will remain responsible for the provisions of this fornia
22
When Covered Services are provided outside of provider and submit the claim yourself to obtain
California and within the BlueCard Service Area reimbursement for these services.
by non-participating providers, the amount you If you need assistance locating a doctor or hospital
pay for such services will normally be based on ei- outside the BlueCard Service Area you should call
ther the Host Blue's non-participating provider lo- the service center at 1-800-810-BLUE (2583) or
cal payment, the Allowable Amount Blue Shield call collect at 1-804-673-1177, 24 hours a day,
pays a Non-Participating Provider in California if seven days a week. Provider information is also
the Host Blue has no non-participating provider al- available online at www.bcbs.com: select "Find a
lowance, or the pricing arrangements required by Doctor" and then"Blue Shield Global Core".
applicable state law. In these situations, you will
be responsible for any difference between the Prior authorization is not required for Emergency
amount that the non-participating provider bills Services. In an emergency, go directly to the near-
and the payment Blue Shield will make for Cov- est hospital. Please see the Benefits Management
ered Services as set forth in this paragraph. Program section for additional information on
If you do not see a participating provider through emergency admission notification.
the BlueCard Program, you will have to pay the Submitting a Blue Shield Global Core Claim
entire bill for your medical care and submit a claim When you pay directly for services outside the
to the local Blue Cross and/or Blue Shield plan, or BlueCard Service Area, you must submit a claim
to Blue Shield of California for reimbursement. to obtain reimbursement. You should complete a
Blue Shield will review your claim and notify you Blue Shield Global Core claim form and send the
of its coverage determination within 30 days after claim form along with the provider's itemized bill
receipt of the claim;you will be reimbursed as de- to the service center at the address provided on the
scribed in the preceding paragraph. Remember, form to initiate claims processing. Following the
your share of cost is higher when you see a non- instructions on the claim form will help ensure
participating provider. timely processing of your claim.The claim form is
Federal or state law, as applicable, will govern available from Blue Shield Customer Service, the
payments for out-of-network Emergency Services. service center or online at www.bcbsglobal-
Blue Shield pays claims for covered Emergency core.com. If you need assistance with your claim
Services based on the Allowable Amount as de- submission,you should call the service center at I-
fined in this EOC. 800-810-BLUE (2583) or call collect at 1-804-
673-1177, 24 hours a day, seven days a week.
Blue Shield Global Core
Special Cases: Value-Based Programs
Care for Covered Urgent and Emergency
Services Outside the BlueCard Service Area Blue Shield Value-Based Programs
If you are outside of the BlueCard® Service Area, You may have access to Covered Services from
you may be able to take advantage of Blue Shield providers that participate in a Blue Shield Value-
Global Core when accessing Out-of-Area Covered Based Program. Blue Shield Value-Based Pro-
Health Care Services. Blue Shield Global Core is grams include, but are not limited to, Accountable
unlike the BlueCard Program available within the Care Organizations, Episode Based Payments, Pa-
BlueCard Service Area in certain ways. For in- tient Centered Medical Homes, and Shared Sav-
stance, although Blue Shield Global Core assists ings arrangements.
you with accessing a network of inpatient, outpa- If you receive covered services under a Blue
tient, and professional providers, the network is Shield Value-Based Program, you will not be re-
not served by a Host Blue. As such, when you re- sponsible for paying any of the Provider Incen-
ceive care from providers outside the BlueCard tives, risk-sharing, and/or Care Coordinator Fees
Service Area, you will typically have to pay the that are a part of such an arrangement.
23
BlueCard®Program Prior Authorization
If you receive Covered Services under a Value- Prior authorization allows the Member and
Based Program inside a Host Blue's service area, provider to verify with Blue Shield or Blue
you will not be responsible for paying any of the Shield's MHSA that (1) the proposed services are
Provider Incentives, risk-sharing, and/or Care Co- a Benefit of the Member's Plan, (2) the proposed
ordinator Fees that are a part of such an arrange- services are Medically Necessary, and (3) the pro-
ment, except when a Host Blue passes these fees posed setting is clinically appropriate. The prior
to Blue Shield through average pricing or fee authorization process also informs the Member
schedule adjustments. and provider when Benefits are limited to services
rendered by Participating Providers or MHSA Par-
Utilization Management ticipating Providers (See the Summary of Bene-
State law requires that Health Plans disclose to fits).
Members and Health Plan providers the process If prior authorization is not obtained by a Partici-
used to authorize or deny health care services un- pating Provider when required, Blue Shield may
der the Plan. Blue Shield has completed documen- deny payment to the Provider. The Member will
tation of this process as required under Section only be responsible for any applicable De-
1363.5 of the California Health and Safety Code. ductibles, Copayment and Coinsurance.
The document describing Blue Shield's Utilization If prior authorization was not obtained by a Non-
Management Program is available online at Participating Provider when required and services
www.blueshieldca.com or Members may call the provided to the Member are determined not to be
Customer Service Department at the number pro- a Benefit of the Plan or were not Medically Neces-
vided on the back page of this EOC to request a sary, coverage will be denied.
copy. For all Prior Authorizations, except prescrip-
Benefits Management Program tion Drugs covered under the medical benefit:
A decision will be made on all requests for prior
The Benefits Management Program applies uti- authorization within five business days from re-
lization management and case management princi- ceipt of the request. The treating provider will be
ples to assist Members and providers in identify- notified of the decision within 24 hours and writ-
ing the most appropriate and cost-effective way to ten notice will be sent to the Member and provider
use the Benefits provided under this Health Plan. within two business days of the decision. For Ur-
The Benefits Management Program includes prior gent Services when the routine decision making
authorization requirements for various medical process might seriously jeopardize the life or
benefits, including inpatient admissions, outpa- health of a Member or when the Member is expe-
tient services,and prescription Drugs administered son as severe pain,a decision will the
rendered as
in the office,infusion center or provided by a home soon as possible to accommodate the r e receipt
o
infusion agency, as well as emergency admission condition, not to exceed 72 hours from receipt of
the request.
notification,and inpatient utilization management.
The program also includes Member services such For Prior Authorizations of prescription Drugs
as, discharge planning, case management and,pal- covered under the medical benefit: Drugs ad-
liative care services. ministered in the office, infusion center or pro-
The following sections outline the requirements of vided by a home infusion agency are covered as a
the Benefits Management Program. medical benefit. For these prescription Drugs,
once all required supporting information is re-
ceived, Blue Shield will provide prior authoriza-
tion approval or denial, based upon Medical Ne-
cessity, within 72 hours in routine circumstances
24
or 24 hours in exigent circumstances. Exigent cir- Provider. If prior authorization was not obtained
cumstances exist when a Member has a health con- and the medical services or Drugs provided to the
dition that may seriously jeopardize the Member's Member were not provided by a Participating
life, health, or ability to regain maximum function Provider when required, coverage will be denied.
or when a Member is undergoing a current course
of treatment using a Non-Formulary Drug. Prior Authorization for Medical Hospital and
Skilled Nursing Facility Admissions
Prior Authorization for Radiological and Nu- Prior authorization is required for all non-emer-
clear Imaging Procedures gency Hospital admissions including admissions
Prior authorization is required for radiological and for acute medical or surgical care, inpatient Reha-
nuclear imaging procedures. The Member or bilitative Services, Skilled Nursing care, special
provider should call 1-888-642-2583 for prior au- transplant and bariatric surgery. The Member or
thorization of the following radiological and nu- provider should call Customer Service at least five
clear imaging procedures when performed on an business days prior to the admission. For Special
outpatient, non-emergency basis: Transplant and Bariatric Services for Residents of
1) CT(Computerized Tomography) scan Designated Counties, failure to obtain prior autho-
rization will result in a denial of coverage.
2) MRI (Magnetic Resonance Imaging)
When inpatient Hospital admission is authorized
3) MRA (Magnetic Resonance Angiography) to a Non-Participating Hospital, the Member will
4) PET (Positron Emission Tomography) scan be responsible for applicable Deductible, Copay-
ment and Coinsurance amounts and all charges in
5) Diagnostic cardiac procedures utilizing nu- excess of the Allowable Amount.
clear medicine
For authorized services from a Non-Participating
Provider, the Member will be responsible for ap- Prior authorization is not required for an emer-
plicable Deductible, Copayment and Coinsurance gency Hospital admission; See the Emergency Ad-
amounts and all charges in excess of the Allowable mission Notification section for additional infor-
Amount. mation.
Prior Authorization for Medical Services and Prior Authorization for Mental Health or Sub-
Prescription Drugs Included on the Prior Au- stance Use Disorder Hospital Admissions and
thorization List Other Outpatient Services
Failure to obtain prior authorization for hemo- Prior authorization is required for all non-emer-
philia home infusion products and services, home gency mental health or substance use disorder
infusion/home injectable therapy or routine patient Hospital admissions including acute inpatient care
care delivered in a clinical trial for treatment of and Residential Care. The provider should call
cancer or life-threatening condition will result in a Blue Shield's Mental Health Service Administra-
denial of coverage. To obtain prior authorization, for (MHSA) at 1-877-263-9952 at least five busi-
the Member or provider should call Customer Ser- ness days prior to the admission. Other Outpatient
vice at the number listed on the back page of this Mental Health and Substance Use Disorder Ser-
EOC. vices, including, but not limited to, Behavioral
Health Treatment, Partial Hospitalization Program
For authorized services and Drugs from allon- (PHP), Intensive Outpatient Program (IOP), elec-
Participating Provider,the Member will be respon- troconvulsive therapy,Office-Based Opioid Treat-
sible for applicable Deductible, Copayment and ment (OBOT), Psychological Testing, and Tran-
Coinsurance amounts and all charges in excess of scranial Magnetic Stimulation (TMS)must also be
the Allowable Amount. prior authorized by the MHSA.
For certain medical services and Drugs, Benefits
are limited to services rendered by a Participating
25
For an authorized admission to a Non-Participat- Hospital discharge planners to determine the most
ing Hospital or authorized Other Outpatient Men- appropriate and cost effective way to provide this
tal Health and Substance Use Disorder Services care.
from a Non-Participating Provider, the Member
will be responsible for applicable Deductible, Co- Case Management
payment and Coinsurance amounts and all charges The Benefits Management Program may also in-
in excess of the Allowable Amount. clude case management, which is a service that
Prior authorization is not required for an emer- provides the assistance of a health care profes-
gency mental health or substance use disorder sional to help the Member access necessary ser-
Hospital admission;See the ErnergencyAdmission vices and to make the most efficient use of Plan
Notification section for additional information. Benefits. The Member's nurse case manager may
also arrange for alternative care benefits to avoid
Emergency Admission Notification prolonged or repeated hospitalizations,when med-
When a Member is admitted to the Hospital for ically appropriate. Alternative care benefits are
Emergency Services Blue Shield or Blue Shield's only utilized by mutual consent of the Member,the
MHSA should receive Emergency Admission No- provider,and Blue Shield or Blue Shield's MHSA,
tification within 24 hours or as soon as it is reason- and will not exceed the standard Benefits available
ably possible following medical stabilization. under this Plan.
The approval of alternative benefits is specific to
Inpatient Utilization Management each Member for a specified period of time. Such
Most inpatient Hospital admissions are monitored approval should not be construed as a waiver of
for length of stay; exceptions are noted below. The Blue Shield's right to thereafter administer this
length of an inpatient Hospital stay may be ex- Health Plan in strict accordance with its express
tended or reduced as warranted by the Member's terms. Blue Shield is not obligated to provide the
condition. When a determination is made that the same or similar alternative care benefits to any
Member no longer requires an inpatient level of other Member in any other instance.
care, written notification is given to the attending Palliative Care Services
Physician and to the Member.If discharge does not
occur within 24 hours of notification, the Member In conjunction with Covered Services, Blue Shield
is responsible for all inpatient charges accrued be- provides palliative care services for Members with
yond the 24 hour time frame. serious illnesses. Palliative care services include
Maternity Admissions: the minimum length of the access to physicians and nurse case managers who
inpatient stay is 48 hours for a normal, vaginal de- are trained to assist Members in managing symp-
livery or 96 hours for a Cesarean section unless the toms, in maximizing comfort, safety, autonomy
attending Physician, in consultation with the and well-being,and in navigating a course of care.
mother, determines a shorter inpatient stay is ade- Members can obtain assistance in making in-
quate. formed decisions about therapy, as well as docu-
menting their quality of life choices. Members
Mastectomy:The length of the inpatient stay is de- may call the Customer Service Department to re-
termined post-operatively by the attending Physi- quest more information about these services.
cian in consultation with the Member.
Discharge Planning Principal Benefits and Coverages
If further care at home or in another facility is ap-
(Covered Services)
propriate following discharge from the Hospital, Blue Shield provides the following Medically
Blue Shield or Blue Shield's MHSA will work Necessary Benefits, subject to applicable De-
with the Member, the attending Physician and the ductibles, Copayments, Coinsurance and charges
26
in excess of Benefit maximums, Participating Allergy Testing and Treatment Benefits
Provider provisions and Benefits Management
Program provisions. Coverage for these services is Benefits are provided for allergy testing and treat-
subject to all terms,conditions, limitations and ex- ment, including allergy serum.
clusions of the Contract, including any conditions
or limitations set forth in the Benefit descriptions Ambulance Benefits
below, and to the Principal Limitations, Excep- Benefits are provided for (1) emergency ambu-
tions, Exclusions and Reductions listed in this lance services(surface and air)when used to trans-
EOC.All Benefits mustbe Medically Necessary to port a Member from place of illness or injury to the
be covered. closest medical facility where appropriate treat-
The Copayment and Coinsurance amounts for ment can be received; or (2) pre-authorized, non-
Covered Services, if applicable, are shown on the emergency ambulance transportation (surface and
Summary of Benefits. The Summary of Benefits is air) from one medical facility to another. Ambu-
provided with, and is incorporated as part of, this lance services are required to be provided by a li-
EOC. censed ambulance or a psychiatric transport van.
Except as may be specifically indicated, for ser- Ambulatory Surgery Center Benefits
vices received from Non-Participating Providers,
Subscribers will be responsible for all charges Benefits are provided for surgery performed in an
above the Allowable Amount in addition to the in- Ambulatory Surgery Center.
dicated Copayment or Coinsurance amount. Barlatric Surgery Benefits
Except as specifically provided herein,services are
covered only when rendered by an individual or Benefits are provided for Hospital and profes-
entity that is licensed or certified by the state to sional services in connection with bariatric surgery
provide health care services and is operating to treat morbid or clinically severe obesity as de-
within the scope of that license or certification. scribed below.
Acupuncture Benefits All bariatric surgery services must be prior autho-
rized, in writing, from Blue Shield, whether the
For all acupuncture services, Blue Shield has con- Member is a resident of a designated or non-desig-
tracted with American Specialty Health Plans of nated county. See the Benefits Management Pro-
California, Inc. (ASH Plans) to act as the Plan's gram section for more information.
acupuncture services administrator.
Benefits are provided for acupuncture evaluation
Services for Residents of Designated Counties
and treatment by a Physician, licensed acupunctur- For Members who reside in a California county
ist, or other appropriately licensed or certified designated as having facilities contracting with
Health Care Provider. Blue Shield to provide bariatric services (see the
Contact ASH Plans with questions about acupunc- list of designated counties below),Blue Shield wil I
ture services, ASH Participating Providers, or provide Benefits for certain Medically Necessary
bariatric surgery procedures only if:
acupuncture Benefits. Contact ASH Plans at:
1) performed at a Participating Hospital or Am-
1-800-678-9133 bulatory Surgery Center,and by a Participating
American Specialty Health Plans of California,
Inc. Provider, that have both contracted with Blue
9002 Shield as a Bariatric Surgery Services Provider
P.O. Box 50
San Diego, 90 92150-9002 to provide the procedure;
ASH Plans can answer many questions over the 2) the services are consistent with Blue Shield's
medical policy; and
telephone.
27
3) prior authorization is obtained,in writing,from 1) Transportation to and from the facility up to a
Blue Shield's Medical Director. maximum of$130 per round trip:
Blue Shield reserves the right to review all re- a. for the Member for a maximum of three
quests for prior authorization for these bariatric trips:
Benefits and to make a decision regarding Benefits i) one trip for a pre-surgical visit;
based on: (1) the medical circumstances of each
patient; and (2) consistency between the treatment ii) one trip for the surgery; and
proposed and Blue Shield medical policy. iii) one trip for a follow-up visit.
For Members who reside in a designated county, b. for one companion for a maximum of two
failure to obtain prior written authorization as de- trips:
scribed above and/or failure to have the procedure
performed at a Participating Hospital or Ambula- i) one trip for the surgery; and
tory Surgery Center by a Bariatric Surgery Ser- ii) one trip for a follow-up visit.
vices Provider will result in denial of claims for
this Benefit. 2) Hotel accommodations not to exceed $100 per
day:
Services for follow-up bariatric surgery proce-
dures, such as lap-band adjustments, must also be a) for the Member and one companion for a
provided by a Physician participating as a Bariatric maximum of two days per trip:
Surgery Services Provider. i) one trip for a pre-surgical visit; and
The following are the designated counties in which ii) one trip for a follow-up visit.
Blue Shield has designated Bariatric Surgery Ser- b) for one companion for a maximum of four
vices Providers to provide bariatric services: days for the duration of the surgery admis-
Imperial San Bernardino sion.
Kern San Diego i) Hotel accommodation is limited to one,
Los Angeles Santa Barbara double-occupancy room. Expenses for
in-room and other hotel services are
Orange Ventura specifically excluded.
Riverside 3) Related expenses judged reasonable by Blue
Bariatric Travel Expense Reimbursement For Shield not to exceed $25 per day per Member
Residents of Designated Counties up to a maximum of four days per trip. Ex-
penses for tobacco, alcohol, drugs, telephone,
Members who reside in designated counties and television, delivery, and recreation are specifi-
who have obtained written authorization from cally excluded.
Blue Shield to receive bariatric services at a Hos-
pital or Ambulatory Surgery Center designated as Submission of adequate documentation including
a Bariatric Surgery Services Provider may be eli- receipts is required before reimbursement will be
gible to receive reimbursement for associated made.
travel expenses. Services for Residents of Non-Designated
To be eligible to receive travel expense reimburse- Counties
ment, the Member's home must be 50 or more Bariatric surgery services for residents of non-des-
miles from the nearest Hospital or Ambulatory ignated counties will be paid as any other surgery
Surgery Center designated as a Bariatric Surgery as described elsewhere in this section when:
Services Provider. All requests for travel expense
reimbursement must be prior authorized by Blue 1) services are consistent with Blue Shield's med-
Shield. Approved travel-related expenses will be ical policy; and
reimbursed as follows:
28
2) prior authorization is obtained,in writing,from 2) the Member provides medical and scientific in-
Blue Shield's Medical Director. formation establishing that the Member's par-
For Members who reside in non-designated coun- ticipation in the clinical trial would be appro-
ties, travel expenses associated with bariatric priate.
surgery services are not covered. Services for routine patient care will be paid on the
same basis and at the same Benefit levels as other
Chiropractic Benefits Covered Services shown in the Summary of Bene-
For all chiropractic services, Blue Shield has con- fits.
tracted with ASH Plans to act as the Plan's chiro- "Routine patient care" consists of those services
practic services administrator. that would otherwise be covered by the Plan if
Benefits are provided for chiropractic services ren- those services were not provided in connection
dered by a chiropractor or other appropriately li- With an approved clinical trial, but does not in-
censed or certified Health Care Provider. The chi- clude:
ropractic Benefit includes the initial examination, 1) the investigational item, device, or service, it-
subsequent office visits, adjustments, and plain self;
film X-ray services in a chiropractor's office. 2) drugs or devices that have not been approved
Benefits are limited to a per Member per Calendar by the federal Food and Drug Administration
Year visit maximum as shown on the Summary of (FDA);
Benefits. 3) services other than health care services,such as
Contact ASH Plans with questions about chiro- travel,housing,companion expenses and other
practic services, ASH Participating Providers, or non-clinical expenses;
chiropractic Benefits. Contact ASH Plans at: 4) any item or service that is provided solely to
1-800-678-9133 satisfy data collection and analysis needs and
American Specialty Health Plans of California, that is not used in the direct clinical manage-
Inc. ment of the patient;
P.O. Box 509002 5) services that, except for the fact that they are
San Diego, CA 92150-9002 being provided in a clinical trial, are specifi-
ASH Plans can answer many questions over the cally excluded under the Plan;
telephone. 6) services customarily provided by the research
Clinical Trial for Treatment of Cancer sponsor free of charge for any enrollee in the
or Life-Threatening Conditions Benefits trial;
7) any service that is clearly inconsistent with
Benefits are provided for routine patient care for widely accepted and established standards of
Members who have been accepted into an ap- care for a particular diagnosis.
proved clinical trial for treatment of cancer or a
life-threatening condition where the clinical trial "Approved clinical trial"means a phase I,phase II,
has a therapeutic intent and when prior authorized phase III or phase IV clinical trial conducted in re-
by Blue Shield, and: lation to the prevention, detection or treatment of
cancer and other life-threatening condition, and is
1) the Member's Physician or another Participat- limited to a trial that is:
ing Provider determines that the Member's
participation in the clinical trial would be ap- 1) federally funded and approved by one or more
propriate based on either the trial protocol or of the following:
medical and scientific information provided by a. one of the National Institutes of Health;
the Member; or
29
b. the Centers for Disease Control and Pre- 2) insulin pumps and all related necessary sup-
vention; plies;
c, the Agency for Health Care Research and 3) podiatric devices to prevent or treat diabetes-
Quality; related complications, including extra-depth
d. the Centers for Medicare & Medicaid Ser- orthopedic shoes; and
vices; 4) visual aids, excluding eyewear and/or video-
e. a cooperative group or center of any of the assisted devices, designed to assist the visually
entities in a)to d)above; or the federal De- impaired with proper dosing of insulin.
partments of Defense or Veterans Admin- For coverage of diabetic testing supplies including
istration; blood and urine testing strips and test tablets,
f. a qualified non-governmental research en- lancets and lancet puncture devices and pen deliv-
tity identified in the guidelines issued by ery systems for the administration of insulin, refer
Sup-
the National Institutes of Health for center to the Outpatient Prescription Drug Benefits Sup-
support grants; plement if selected as an optional Benefits by your
Employer.
g. the federal Veterans Administration, De-
partment of Defense, or Department of En- Diabetic Outpatient Self-Management
ergy where the study or investigation is re- Training
viewed and approved through a system of Benefits are provided for diabetic outpatient self-
peer review that the Secretary of Health & management training, education and medical nu-
Human Services has determined to be com- trition therapy to enable a Member to properly use
parable to the system of peer review of the devices,equipment and supplies,and any addi-
studies and investigations used by the Na- tional outpatient self-management training, educa-
tional Institutes of Health, and assures un- tion and medical nutrition therapy when directed
biased review of the highest scientific stan- or prescribed by the Member's Physician. These
dards by qualified individuals who have no Benefits shall include, but not be limited to, in-
interest in the outcome of the review; or struction that will enable diabetic patients and their
2) the study or investigation is conducted under families to gain an understanding of the diabetic
an investigational new drug application re- disease process, and the daily management of dia-
viewed by the Food and Drug Administration betic therapy, in order to avoid frequent hospital-
or is exempt under federal regulations from a izations and complications. Services will be cov-
new drug application. ered when provided by a Physician, registered di-
etician, registered nurse, or other appropriately li-
"Life-threatening condition" means any disease or censed Health Care Provider who is certified as a
condition from which the likelihood of death is diabetes educator.
probable unless the course of the disease or condi-
tion interrupted. Dialysis Benefits
Diabetes Care Benefits Benefits are provided for dialysis services, includ-
ing renal dialysis, hemodialysis, peritoneal dialy-
Diabetic Equipment sis and other related procedures.
Benefits are provided for the following devices Included in this Benefit are dialysis related labora-
and equipment,including replacement after the ex- tory tests, equipment, medications, supplies and
pected life of the item, for the management and dialysis self-management training for home dialy-
treatment of diabetes: sis.
1) blood glucose monitors, including those de-
signed to assist the visually impaired;
30
Durable Medical Equipment Benefits and supplies that are reasonable and necessary for
the palliation and management of Terminal Disease
Benefits are provided for Durable Medical Equip- or Terminal Illness and related conditions are pro-
ment (DME) for Activities of Daily Living, sup- vided by the Hospice Agency.
plies needed to operate Durable Medical Equip-
ment, oxygen and its administration, and ostomy Emergency Room Benefits
and medical supplies to support and maintain gas-
trointestinal,bladder or respiratory function. Other Benefits are provided for Emergency Services pro-
covered items include peak flow monitors for self- vided in the emergency room of a Hospital.For the
management of asthma, the glucose monitor for lowest out-of-pocket expenses, covered non-
self-management of diabetes, apnea monitors for Emergency Services and emergency room follow-
management of newborn apnea, breast pumps and up services (e.g., suture removal, wound check,
the home prothrombin monitor for specific condi- etc.) should be received in a Participating
tions, as determined by Blue Shield. Benefits are Provider's office.
provided at the most cost-effective level of care Emergency Services are services provided for an
that is consistent with professionally recognized Emergency Medical Condition, including a psy-
standards of practice. chiatric Emergency Medical Condition or active
No DME Benefits are provided for the following: labor,manifesting itself by acute symptoms of suf-
ficient severity (including severe,pain) such that
I) rental charges in excess of the purchase cost; the absence of immediate medical attention could
2) replacement of Durable Medical Equipment reasonably be expected to result in any of the fol-
except when it no longer meets the clinical lowing:
needs of the patient or has exceeded the ex- 1) placing the Member's health in serious jeop-
pected lifetime of the item.This exclusion does ardy;
not apply to the Medically Necessary replace-
ment of nebulizers, face masks and tubing, and 2) serious impairment to bodily functions;
peak flow monitors for the management and 3) serious dysfunction of any bodily organ or
treatment of asthma. (See the Outpatient Pre- part,
scription Drug Benefit Supplement, if selected
as an optional Benefit by your Employer, for When a Member is admitted to the Hospital for
benefits for asthma inhalers and inhaler spac- Emergency Services, Blue Shield should receive
ers); Emergency Admission Notification within 24
hours or as soon as it is reasonably possible fol-
3) breast pump rental or purchase when obtained lowing medical stabilization. The services will be
from a Non-Participating Provider; reviewed retrospectively by Blue Shield to deter-
4) repair or replacement due to loss or misuse; mine whether the services were for an Emergency
Medical Condition.
5) environmental control equipment, generators,
self-help/educational devices,air conditioners, Family Planning and Infertility Benefits
humidifiers, dehumidifiers, air purifiers, exer-
cise equipment, or any other equipment not Family Planning
primarily medical in nature; and Benefits are provided for the following family
6) backup or alternate items. planning services without illness or injury being
See the Diabetes Care Benefits section for devices, present:
equipment, and supplies for the management and 1) family planning, counseling and consultation
treatment of diabetes. services, including Physician office visits for
For Members in a Hospice program through a Par- office-administered covered contraceptives;
ticipating Hospice Agency, medical equipment and
31
2) vasectomy. Aide are covered up to four hours per visit,and are
No Benefits are provided for family planning ser- included in the Calendar Year visit maximum.
vices from Non-Participating Providers. For the purpose of this Benefit, each two-hour in-
See also the Preventive Health Benefits section for crement of visit from a nurse, physical therapist,
additional family planning services. occupational therapist, speech therapist, or medi-
cal social worker counts as a separate visit. Visits
For plans with a Calendar Year Deductible for ser- of two hours or less shall be considered as one
vices by Participating Providers, the Calendar visit. For visits from a Home Health Aide, each
Year Deductible applies only to male steriliza- four-hour increment counts as a separate visit.Vis-
tions. its of four hours or less shall be considered as one
Infertility Benefits visit.
Benefits are provided for the diagnosis and treat- Medical supplies used during a covered visit by the
ment of the cause of Infertility, including profes- home health agency necessary for the home health
sional, Hospital, Ambulatory Surgery Center, and care treatment plan and related laboratory services
ancillary services to diagnose and treat the cause are covered in conjunction with the professional
of Infertility, with the exception of what is ex-
cluded in the Principal Limitations, Exceptions, This Benefit does not include medications, or in-
Exclusions and Reductions section. jectables covered under the Home Infusion and
Home Injectable Therapy Benefit or under the Out-
Home Health Care Benefits patient Prescription Drug Benefit Supplement if
Benefits are provided for home health care ser- selected as an optional Benefit by your Employer.
vices from a Participating home health care agency See the Hospice Program Benefits section for in-
when the services are ordered by the Member's formation about admission into a Hospice program
Physician, and included in a written treatment and specialized Skilled Nursing services for Hos-
plan. pice care.
Covered Services are subject to any applicable De- For information concerning diabetic self-manage-
ductibles, Copayments and Coinsurance. Visits by ment training, see the Diabetes Care Benefits sec-
home health care agency providers will be payable tion.
up to a combined per Member per Calendar Year
visit maximum as shown on the Summary of Bene- Home Infusion and Home Injectable
fits. Therapy Benefits
Intermittent and part-time visits by a home health Benefits are provided for home infusion and in-
agency to provide Skilled Nursing and other jectable medication therapy. Services include
skilled services are covered up to four visits per home infusion agency Skilled Nursing visits, infu-
day, two hours per visit up to the Calendar Year sion therapy provided in infusion suites associated
visit maximum (including all home health visits) with a Participating home infusion agency, par-
by any of the following professional providers: enteral nutrition services, enteral nutritional ser-
vices and associated supplements, medical sup-
plies used during a covered visit, medications in-
2) licensed vocational nurse; jected or administered intravenously, related labo-
3) physical therapist, occupational therapist, or ratory services, when prescribed by a Doctor of
speech therapist; or Medicine and provided by a Participating home in-
fusion agency. Services related to hemophilia are
4) medical social worker. described separately.
Intermittent and part-time visits by a home health This Benefit does not include medications, insulin,
agency to provide services from a Home Health insulin syringes, certain Specialty Drugs covered
32
under the Outpatient Prescription Drug Supple- No Benefits are provided for:
ment if selected as an optional Benefit by your Em-
ployer, and Services related to hemophilia which 1) physical therapy, gene therapy or medications
are described below. including antifibrinolytic and hormone medi-
cations;
Services rendered by Non-Participating home in- 2) services from a hemophilia treatment center or
fusion agencies are not covered unless prior autho- any Non-Participating Hemophilia Infusion
rized by Blue Shield, and there is an executed let- Provider; or,
ter of agreement between the Non-Participating
home infusion agency and Blue Shield. 3) self-infusion training programs, other than
Hemophilia Home Infusion Products and Ser- nursing visits to assist in administration of the
vices product.
Services may be covered under Outpatient Pre-
Benefits are provided for home infusion products
for the treatment of hemophilia and other bleeding Benefit
ion Drug Benefits if selected as optional
B
disorders.All services must be prior authorized by Benefit by your Employer, or as described else-
Blue Shield and must be provided by a Participat- Where in this Principal Benefits and Coverages
ing Hemophilia Infusion Provider. (Note: most (Covered Services) section.
Participating home health care and home infusion Hospice Program Benefits
agencies are not Participating Hemophilia Infusion
Providers.) To find a Participating Hemophilia In- Benefits are provided for services through a Par-
fusion Provider, consult the Participating Provider ticipating Hospice Agency when an eligible Mem-
directory. Members may also verify this informa- ber requests admission to, and is formally admit-
tion by calling Customer Service at the telephone ted into, an approved Hospice program.The Mem-
number shown on the last page of this EOC. ber must have a Terminal Disease or Terminal III-
Hemophilia Infusion Providers offer 24-hour ser- ness as determined by his or her Participating
vice and provide prompt home delivery of hemo- Provider's certification and must receive prior ap-
philia infusion products. proval from Blue Shield for the admission. Mem-
bers with a Terminal Disease or Terminal Illness
Following Member evaluation by a Doctor of
Medicine, a prescription for a blood factor product who have not yet elected to enroll in a Hospice
must be submitted to and approved by Blue Shield. Program may receive a hospice consultative
Hospice
Once prior authorized by Blue Shield, the blood visit from a Participating Hospice Agency.
factor product is covered on a regularly scheduled A Hospice program is a specialized form of inter-
basis (routine prophylaxis) or when a non-emer- disciplinary care designed to provide palliative
gency injury or bleeding episode occurs. (Emer- care, alleviate the physical, emotional, social and
gencies will be covered as described in the Emer•- spiritual discomforts of a Member who is experi-
gency Room Benefits section.) encing the last phases of life due to a Terminal
Included in this Benefit is the blood factor product Disease or Terminal Illness, and to provide sup-
portive care to the primary caregiver and the fam-
supplies such as ports and syringes, and necessary seily of the Hospice patient. Medically Necessary
nursing visits. Services for the treatment of hemo- services are available is a program
basis. Mem-
philia outside the home, except for services in in- tors enrolled in a Hospice program may continue
fusion suites managed by a Participating Hemo- to receive Covered Services that are not related t
philia Infusion Provider, and services to treat com- the palliation and management of their Terminal
plications of hemophilia replacement therapy are Disease or Terminal Illness from the appropriate
provider. All of the services listed below must be
not covered under this Benefit. received through the Participating Hospice
Agency.
33
1) Pre-hospice consultative visit regarding pain 4) Continuous home care when Medically Nec-
and symptom management,Hospice and other essary to achieve palliation or management of
care options including care planning. acute medical symptoms including the fol-
2) An interdisciplinary plan of home care devel- lowing:
oped by the Participating Hospice Agency and a. 8 to 24 hours per day of Continuous Nurs-
delivered by appropriately qualified, licensed ing Services (8-hour minimum);
and/or certified staff, including the following: b. homemaker or Home Health Aide Ser-
a. Skilled Nursing services including assess- vices up to 24 hours per day to supplement
ment, evaluation and treatment for pain skilled nursing care.
and symptom control; 5) Short-term inpatient care arrangements when
b. Home Health Aide services to provide palliation or management of acute medical
personal care (supervised by a registered symptoms cannot be achieved at home.
nurse); 6) Short-term inpatient respite care up to five
c. homemaker services to assist in the main- consecutive days per admission on a limited
tenance of a safe and healthy home envi- basis.
ronment (supervised by a registered Members are allowed to change their Participat-
nurse); ing Hospice Agency only once during each Pe-
d. bereavement services for the immediate riod of Care. Members may receive hospice care
surviving family members for a period of for two 90-day periods followed by unlimited 60-
at least one year following the death of the day periods of care, depending on their diagnosis.
Member; The extension of care continues through another
e. medical social services including the uti- Period of Care if the Physician recertifies that the
lization of appropriate community re- Member is Terminally III.
sources; Hospice services provided by a Non-Participating
f. counseling/spiritual services for the Mem- Hospice Agency are not covered except in certain
ber and family; circumstances in counties in California in which
there are no Participating Hospice Agencies and
g. dietary counseling; only when prior authorized by Blue Shield.
h. medical direction provided by a licensed
Doctor of Medicine acting as a consultant Hospital Benefits (Facility Services)
to the interdisciplinary Hospice team and Inpatient Services for Treatment of Illness or
to the Member's Participating Provider Injury
with regard to pain and symptom manage-
ment and as a liaison to community physi- Benefits are provided for the following inpatient
cians; Hospital services:
i. physical therapy, occupational therapy, I) Semi-private room and board unless a private
and speech-language pathology services room is Medically Necessary.
for purposes of symptom control,or to en- 2) General nursing care, and special duty nursing.
able the Member to maintain Activities of 3) Meals and special diets.
Daily Living and basic functional skills;
j. respiratory therapy; 4) Intensive care services and units.
5) Use of operating room, specialized treatment
k. volunteer services. rooms,,delivery room, newborn nursery, and
3) Drugs, durable medical equipment, and sup- related facilities.
plies.
34
6) Surgical supplies,dressings and cast materials, Outpatient Services for Treatment of Illness or
and anesthetic supplies furnished by the Hos- Injury
pital. Benefits include the following outpatient Hospital
7) Inpatient rehabilitation when furnished by the services:
Hospital and approved in advance by Blue 1) Dialysis services.
Shield under its Benefits Management Pro-
gram. 2) Outpatient Care.
8) Drugs and oxygen. ' 3) Surgery.
9) Administration of blood and blood plasma, in- 4) Radiation therapy, chemotherapy for cancer,
cluding the cost of blood,blood plasma and in- including catheterization, infusion devices,
Hospital blood processing. and associated drugs and supplies.
10)Hospital ancillary services, including diagnos- 5) Routine newborn circumcision performed
tic laboratory, X-ray services, and imaging within 18 months of birth.
procedures including MRI, CT and PET scans. Covered Physical Therapy, Occupational Therapy
11)Dialysis, radiation therapy, chemotherapy for and Speech Therapy Services provided in an out-
cancer including catheterization, infusion de- patient Hospital setting are described under the Re-
vices, and associated drugs and supplies. habilitative and Habilitative Benefits (Physical,
Occupational and Respiratory Therapy) and
12)Surgically implanted devices and prostheses,
Speech Therapy Benefits (Rehabilitative and Ha-
other medical supplies, and medical appliances bilitative Services) sections.
and equipment administered in a Hospital.
13)Subacute Care. Medical Treatment of the Teeth, Gums,
14)Medical social services and discharge plan- or Jaw Joints and Jaw Bones Benefits
ning. Benefits are provided for Hospital and profes-
15)Inpatient services including general anesthesia sional services provided for conditions of the teeth,
and associated facility charges in connection gums or jaw joints and jaw bones, including adja-
with dental procedures when hospitalization is cent tissues, only to the extent that they are pro-
required because of an underlying medical vided for:
condition or clinical status and the Member is 1) treatment of tumors of the gums;
under the age of seven or developmentally dis-
abled regardless of age or when the Member's 2) treatment of damage to natural teeth caused
health is compromised and for whom general solely by an Accidental Injury (limited to pal-
anesthesia is Medically Necessary regardless liative services necessary for the initial medi-
of age. Excludes dental procedures and ser- cal stabilization of the Member as determined
vices of a dentist or oral surgeon. by Blue Shield);
16)Inpatient substance use disorder detoxification 3) non-surgical treatment (e.g., splint and physi-
services required to treat symptoms of acute cal therapy) of Temporomandibular Joint Syn-
toxicity or acute withdrawal when a Member is drome (TMJ);
admitted through the emergency room, or 4) surgical and arthroscopic treatment of TMJ if
when inpatient substance use disorder detoxi- prior history shows conservative medical treat-
fication is prior authorized by Blue Shield. ment has failed;
5) treatment of maxilla and mandible (jaw joints
and jaw bones);
6) orthognathic surgery (surgery to reposition the
35
upper and/or lower jaw) to correct a skeletal vices for Blue Shield Members within California.
deformity; See the Out-Of-Area Services, B1ueCard Program
7) dental and orthodontic services that are an in- section for an explanation of how payment is made
tegral part of Reconstructive Surgery for cleft for out of state services.
palate repair; All Non-Emergency inpatient Mental Health and
8) dental evaluation, X-rays, fluoride treatment Substance Use Disorder Services, including Resi-
and extractions necessary to prepare the Mem- dential Care, and Other Outpatient Mental Health
ber's jaw for radiation therapy of cancer in the and Substance Use Disorder Services are subject
head or neck; to the Benefits Management Program and must be
prior authorized by the MHSA. See the Benefits
9) general anesthesia and associated facility Management Program section for complete infor-
charges in connection with dental procedures mation
when performed in an Ambulatory Surgery Office Visits for Outpatient Mental Health and
Center or Hospital due to the Member's under-lying medical condition or clinical status and Substance Use Disorder Services
the Member is under the age of seven or devel- Benefits are provided for professional (Physician)
opmentally disabled regardless of age or when office visits for the diagnosis and treatment of
the Member's health is compromised and for Mental Health Conditions and Substance Use Dis-
whom general anesthesia is Medically Neces- order Conditions in the individual,family or group
sary regardless of age. This benefit excludes setting
dental procedures and services of a dentist or Other Outpatient Mental Health and Substance
oral surgeon. Use Disorder Services
No Benefits are provided for: Benefits are provided for Outpatient Facility and
1) orthodontia (dental services to correct irregu- professional services for the diagnosis and treat-
larities or malocclusion of the teeth) for any ment of Mental Health and Substance Use Disor-
reason other than reconstructive treatment of der Conditions. These services may also be pro-
cleft palate, including treatment to alleviate vided in the office,home or other non-institutional
TMJ; setting. Other Outpatient Mental Health and Sub-
2) dental implants (endosteal, subperiosteal or stance Use Disorder Services include, but may not
transosteal); be limited to, the following:
3 an procedure e. vestibulo las intended 1) Behavioral Health Treatment (BHT)—profes-
Y P ( g•, P tY) •
to prepare the mouth for dentures or for the sional services and treatment programs, in-
more comfortable use of dentures; cluding applied behavior analysis and evi-
dence-based intervention programs, which de-
4) alveolar ridge surgery of the jaws if performed velop or restore, to the maximum extent prac-
primarily to treat diseases related to the teeth, ticable, the functioning of an individual with
gums or periodontal structures or to support pervasive developmental disorder or autism.
natural or prosthetic teeth; and
BHT is covered when prescribed by a physi-
5) fluoride treatments except when used with ra- cian or licensed psychologist and provided un-
diation therapy to the oral cavity. der a treatment plan approved by the MHSA.
Mental Health and Substance Use Treatment used for the purposes of providing
Disorder Benefits respite, day care, or educational services, or to
reimburse a parent for participation in the treat-
Blue Shield's Mental Health Service Administra- ment is not covered.
for (MHSA) arranges and administers Mental 2) Electroconvulsive Therapy —the passing of a
Health Services and Substance Use Disorder Ser- small electric current through the brain to in-
36
duce a seizure, used in the treatment of severe I) shoes only when permanently attached to such
mental health conditions. appliances;
3) Intensive Outpatient Program — an outpatient 2) special footwear required for foot disfigure-
mental health or substance use disorder treat- ment which includes, but is not limited to, foot
ment program utilized when a patient's condi- disfigurement from cerebral palsy, arthritis,
tion requires structure, monitoring, and medi- polio, spina bifida, and foot disfigurement
cal/psychological intervention at least three caused by accident or developmental disabil-
hours per day, three days per week. ity;
4) Office-Based Opioid Treatment — outpatient 3) knee braces for post-operative rehabilitation
opioid detoxification and/or maintenance ther- following ligament surgery, instability due to
apy, including methadone maintenance treat- injury, and to reduce pain and instability for
ment patients with osteoarthritis;
5) Partial Hospitalization Program—an outpatient 4) functional foot orthoses that are custom made
treatment program that may be free-standing or rigid inserts for shoes, ordered by a physician
Hospital-based and provides services at least or podiatrist, and used to treat mechanical
five hours per day, four days per week. Mem- problems of the foot, ankle or leg by prevent-
bers may be admitted directly to this level of ing abnormal motion and positioning when im-
care, or transferred from acute inpatient care pr6vement has not occurred with a trial of
following stabilization. strapping or an over-the-counter stabilizing de-
6) Psychological Testing — testing to diagnose a vice;
Mental Health Condition when referred by an 5) initial fitting and adjustment of these devices,
MHSA Participating Provider. their repair or replacement after the expected
7) Transcranial Magnetic Stimulation—a non-in- life of the orthosis is covered.
vasive method of delivering electrical stimula- No Benefits are provided for orthotic devices such
tion to the brain for the treatment of severe de- as knee braces intended to provide additional sup-
pression. port for recreational or sports activities or for or-
Inpatient Services thopedic shoes and other supportive devices for the
feet not listed above. No Benefits are provided for
Benefits are provided for inpatient Hospital and backup or alternate items, or replacement due to
professional services in connection with acute hos- loss or misuse.
pitalization for the treatment of Mental Health
Conditions or Substance Use Disorder Conditions. See the Diabetes Care Benefits section for devices,
equipment, and supplies for the management and
Benefits are provided for inpatient and profes- treatment of diabetes.
sional services in connection with Residential Care
admission for the treatment of Mental Health Con- Outpatient X-ray, Pathology and
ditions or Substance Use Disorder Conditions. Laboratory Benefits
See Hospital Benefits (Facility Services),Inpatient Benefits are provided for X-ray services, diagnos-
Services for Treatment of Illness or Injury for in- tic testing, clinical pathology, and laboratory ser-
formation on Medically Necessary inpatient sub- vices when provided to diagnose illness or injury.
stance use disorder detoxification.
Benefits are provided for genetic testing for at-risk
Orthoties Benefits Members according to Blue Shield medical policy
and for prenatal genetic screening and diagnostic
Benefits are provided for orthotic appliances and services as follows:
devices for maintaining normal Activities of Daily
Living only. Benefits include: 1) prenatal genetic screening to identify women
37
who are at increased risk for carrying a fetus 6) outpatient routine newborn circumcisions per-
with a specific genetic disorder; formed within 18 months of birth.
2) prenatal diagnosis of genetic disorders of the See the Outpatient X-ray, Pathology and Labora-
fetus by means of diagnostic procedures in tory Benefits section for information on prenatal
case of high-risk pregnancy. genetic screening and diagnosis of genetic disor-
See the section on Radiological andNuclearlmag- ders of the fetus for high risk pregnancy.
ing Benefits for additional diagnostic procedures The Newborns' and Mothers' Health Protection
which require prior authorization by Blue Shield. Act requires health plans to provide a minimum
Routine laboratory services performed as part of a Hospital stay for the mother and newborn child of
preventive health screening are covered under the 48 hours after a normal, vaginal delivery and 96
Preventive Health Benefits section. hours after a C-section unless the attending Physi-
cian, in consultation with the mother, determines a
PKU Related Formulas and Special shorter Hospital length of stay is adequate.
Food Products Benefits If the Hospital stay is less than 48 hours after a nor-
mal, vaginal delivery or less than 96 hours after a
Benefits are provided for enteral formulas, re- C-section, a follow-up visit for the mother and
lated medical supplies,and Special Food Products newborn within 48 hours of discharge is covered
for the dietary treatment of phenylketonuria when prescribed by the treating Physician. This
(PKU). All formulas and Special Food Products visit shall be provided by a licensed Health Care
must be prescribed and ordered through the appro- Provider whose scope of practice includes postpar-
priate health care professional. tum and newborn care. The treating Physician, in
Podiatrie Benefits consultation with the mother, shall determine
whether this visit shall occur at home, the con-
Podiatric services include office visits and other tracted facility, or the Physician's office.
Covered Services for the diagnosis and treatment
of the foot, ankle and related structures.These ser- Preventive Health Benefits
vices, including surgical procedures,are customar- Preventive Health Services are only covered when
ily provided by a licensed doctor of podiatric rendered by a Participating Provider. These ser-
medicine. Covered lab and X-ray services pro- vices include primary preventive medical screen-
vided in conjunction with this Benefit are de- ing and laboratory testing for early detection of
scribed under the Outpatient X-ray, Pathology and disease as specifically listed below:
Laboratory Benefits section.
1) evidence-based items, drugs or services that
Pregnancy and Maternity Care Benefits have in effect a rating of"A"or`B"in the cur-
rent recommendations of the United States
Benefits are provided for maternity services, in- Preventive Services Task Force;
cluding the following:
2) immunizations that have in effect a recommen-
I) prenatal care; dation from either the Advisory Committee on
2) outpatient maternity services; Immunization Practices of the Centers for Dis-
3) involuntary complications of pregnancy (in- ease Control and Prevention, or the most cur-
cluding puerperal infection, eclampsia, ce- rent version of the Recommended Childhood
sarean section delivery,ectopic pregnancy,and Immunization Schedule/United States, jointly
toxemia); adopted by the American Academy of Pedi-
atrics, the Advisory Committee on Immuniza-
4) inpatient hospital maternity care including la- tion Practices, and the American Academy of
bor, delivery and post-delivery care; Family Physicians;
5) abortion services; and
38
3) with respect to infants, children, and adoles- 5) Visits to the home, Hospital, Skilled Nursing
cents, evidence-informed preventive care and Facility and Emergency Room.
screenings provided for in the comprehensive 6) Routine newborn care in the Hospital includ-
guidelines supported by the Health Resources ing physical examination of the baby and coun-
and Services Administration; seling with the mother concerning the baby
4) with respect to women,such additional preven- during the Hospital stay.
tive care and screenings not described in para- 7) Surgical procedures. Chemotherapy for can-
graph 1) as provided for in comprehensive cer, including catheterization, and associated
guidelines supported by the Health Resources drugs and supplies.
and Services Administration.
Preventive Health Services include, but are not 8) Extra time spent when a Physician is detained
limited to, cancer screening (including, but not to treat a Member in critical condition.
limited to, colorectal cancer screening, cervical 9) Necessary preoperative treatment.
cancer and HPV screening, breast cancer screen- 10)Treatment of burns.
ing and prostate cancer screening), osteoporosis
screening, screening for blood lead levels in chil- 11)Outpatient routine newborn circumcision per-
dren at risk for lead poisoning, and health educa- formed within 18 months of birth.
tion. More information regarding covered Preven- 12)Diagnostic audiometry examination.
tive Health Services is available at
www.blueshieldca.com/preventive or by calling 13)Teladoc consultations. Teladoc consultations
Customer Service. for primary care services provide confidential
consultations using a network of U.S. board
In the event there is a new recommendation or certified Physicians who are available 24 hours
guideline in any of the resources described in para- a day by telephone and from 7 a.m. and 9 p.m.
graphs 1)through 4)above,the new recommenda- by secure online video, 7 days a week. If your
tion will be covered as a Preventive Health Service Physician's office is closed or you need quick
no later than 12 months following the issuance of access to a Physician,you can call Teladoc toll
the recommendation. free at 1-800-Teladoc (800-835-2362) or visit
Diagnostic audiometry examinations are covered http://www.teladoe.com/bsc. The Teladoc
under the Professional (Physician) Benefits. Physician can provide diagnosis and treatment
for routine medical conditions and can also
Professional (Physician) Benefits prescribe certain medications.
Benefits are provided for services of Physicians for Before this service can be accessed, you must
treatment of illness or injury, as indicated below. complete a Medical History Disclosure form
(MHD).The MHD form can be completed on-
1) Office visits. line on Teladoc's website at no charge or can
2) Services of consultants, including those for be printed, completed and mailed or faxed to
second medical opinion consultations. Teladoc.Teladoc consultation Services are not
3) Mammography and Papanicolaou's tests or intended to replace services from your Physi-
other FDA (Food and Drug Administration) nee but area supplemental service. You do not
approved cervical cancer screening tests. need to contact your Physician before using
Teladoc consultation Services.
4) Asthma self-management training and educa- Teladoc physicians do not issue prescriptions
tion to enable a Member to properly use for substances controlled by the DEA, non-
asthma-related medication and equipment such therapeutic, and/or certain other drugs which
as inhalers, spacers, nebulizers and peak flow may be harmful because of potential for abuse.
monitors.
39
Note: If medications are prescribed, and your traocular lens has been implanted. These con-
Employer selected the optional Outpatient tact lenses will not be covered under this Plan
Prescription Drug Benefit Supplement as a if the Member has coverage for contact lenses
Benefit,the applicable Copayment or Coinsur- through a Blue Shield vision plan;
ante will apply. Teladoc consultation services 4) supplies necessary for the operation of prosthe-
are not available for specialist services or Men-
tal Health and Substance Use Disorder Ser-
vices. However, telehealth services for Mental 5) initial fitting and replacement after the ex-
Health and Substance Use Disorders are avail- petted life of the item; and
able through MHSA Participating Providers. 6) repairs, except for loss or misuse.
14) A Participating Provider may offer extended No Benefits are provided for wigs for any reason
office hours for services on a walk-in basis at or any type of speech or language assistance de-
the Physician's office. These services will be vices (except as specifically provided above). No
reimbursed as Physician office visits. Benefits are provided for backup or alternate
There are also freestanding urgent are centers items.
where the Member can receive urgent care ser- For surgically implanted and other prosthetic de-
vices on a walk-in basis. A list of urgent care vices (including prosthetic bras) provided to re-
providers may be found online at store and achieve symmetry incident to a mastec-
www.blueshieldca.com or from Customer Ser- tomy,see the Reconstructive Surgery Benefits sec-
vice. Urgent care centers are typically open tion.
during regular office hours and beyond.
Professional services by providers other than Radiological and Nuclear Imaging
Physicians are described elsewhere under Covered Benefits
Services. The following radiological and nuclear imaging
Covered lab and X-ray services provided in con- procedures, when performed on an Outpatient,
junction with these professional services listed non-emergency basis, require prior authorization
above are described under the Outpatient X-ray, under the Benefits Management Program. See the
Pathology and Laboratory Benefits section. Benefits Management Program section for com-
plete information.
Prosthetic Appliances Benefits 1) CT(Computerized Tomography) scans;
Benefits are provided for Prostheses for Activities 2) MRIs (Magnetic Resonance Imaging);
of Daily Living at the most cost-effective level of
care that is consistent with professionally recog- 3) MRAs (Magnetic Resonance Angiography);
nized standards of practice. Benefits include: 4) PET (Positron Emission Tomography) scans;
1) Tracheoesophageal voice prosthesis (e.g. and
Blom-Singer device), artificial larynx or other 5) Cardiac diagnostic procedures utilizing nu-
prosthetic device for speech following laryn- clear medicine.
gectomy, artificial limbs and eyes;
2) internally implanted devices such as pacemak- Reconstructive Surgery Benefits
ers, intraocular lenses, cochlear implants, os- Benefits are provided to correct or repair abnormal
seointegrated hearing devices and hip joints if structures of the body caused by congenital de-
surgery to implant the device is covered; fects, developmental abnormalities, trauma, infec-
3) contact lenses to treat eye conditions such as tion, tumors, or disease to do either of the follow-
keratoconus or keratitis sicca, aniridia, or ing: (1)to improve function, or(2)to create a nor-
aphakia following cataract surgery when no in- mal appearance to the extent possible.Benefits in-
40
clude dental and orthodontic services that are an fits. The Benefit maximum is per Member per
integral part of this surgery for cleft palate proce- Benefit Period, except that room and board
dures. Reconstructive Surgery is covered to create charges in excess of the facility's established semi-
a normal appearance only when it offers more than private room rate are excluded.A"Benefit Period"
a minimal improvement in appearance. begins on the date the Member is admitted into the
In accordance with the Women's Health & Cancer facility for Skilled Nursing services, and ends 60
Rights Act,Reconstructive Surgery,and surgically days after being discharged and Skilled Nursing
implanted and non-surgically implanted prosthetic services are no longer being received. A new Ben-
devices (including prosthetic bras), are covered on Ben-
efit Period can begin only after an existing Benefit
Period ends.
either breast to restore and achieve symmetry inci-
dent to a mastectomy, and treatment of physical Speech Therapy Benefits (Rehabilitative
complications of a mastectomy, including lym-
phedemas. and Habilitative Services)
Benefits will be provided in accordance with Benefits are provided for outpatient Speech Ther-
guidelines established by Blue Shield and devel- apy for the treatment of(1) a communication im-
oped in conjunction with plastic and reconstructive pairment;(2)a swallowing disorder; (3) an expres-
surgeons. sive or receptive language disorder; or (4) an ab-
normal delay in speech development.
Rehabilitative and Habilitative Services Continued outpatient Benefits will be provided as
Benefits (Physical, Occupational and long as treatment is Medically Necessary pursuant
Respiratory Therapy) to the treatment plan, to help the Member regain
his or her previous performance level or to keep,
Benefits are provided for outpatient Physical, Oc- learn, or improve skills and functioning. Blue
cupational, and Respiratory Therapy for the treat- Shield may periodically review the provider's
ment of functional disability in the performance of treatment plan and records for Medical Necessity.
activities of daily living. Continued outpatient
Benefits will be provided as long as treatment is Note: See the Home Health Care Benefits and
Medically Necessary pursuant to the treatment Hospice Program Benefits sections for informa-
plan, to help the Member regain his or her previ- tion on coverage for Speech Therapy Services ven-
ous level of functioning or to keep, learn, or im- dered in the home. See the Hospital Benefits (Fa-
prove skills and functioning. cility Services) section for information on inpatient
Blue Shield may periodically review the provider's Benefits.
treatment plan and records for Medical Necessity. Transplant Benefits
Benefits for Speech Therapy are described in the Transplant benefits include coverage for donation-
Speech Therapy Benefits(Rehabilitative and Habil- related services for a living donor (including a po-
itative Services) section. tential donor), or a transplant organ bank. Donor
See the Home Health Care Benefits and Hospice services must be directly related to a covered trans-
Program Benefits sections for information on cov- plant and must be prior authorized by Blue Shield.
erage for Rehabilitative/Habilitative services ren- Donation-related services include harvesting of the
dered in the home. organ, tissue, or bone marrow and treatment of
medical complications for a period of 90 days fol-
Skilled Nursing Facility Benefits lowing the evaluation or harvest service.
Benefits are provided for Skilled Nursing services Tissue and Kidney Transplants
in a Skilled Nursing unit of a Hospital or a free- Benefits are provided for Hospital and profes-
standing Skilled Nursing Facility, up to the Bene- sional services provided in connection with human
fit maximum as shown on the Summary of Bene-
41
tissue and kidney transplants when the Member is Principal Limitations, Exceptions,
the transplant recipient. Exclusions and Reductions
Benefits include services incident to obtaining the
human transplant material from a living donor or a General Exclusions and Limitations
tissue/organ transplant bank.
Special Transplants No Benefits are provided for the following:
1) routine physical examinations, immunizations
Benefits are provided for certain procedures, listed
and vaccinations by any mode of administra-
below, only if: (1) performed at a Special Trans- tion solely for the purpose of travel, licensure,
plant Facility contracting with Blue Shield to pro- employment, insurance, court order, parole, or
vide the procedure, or in the case of Members ac- probation.This exclusion shall not apply to
cessing this Benefit outside of California, the pro- Medically Necessary services which Blue
cedure is performed at a transplant facility desig- Shield is required by law to cover for Severe
nated by Blue Shield, (2)prior authorization is ob- Mental Illnesses or Serious Emotional Distur-
tained, in writing through the Benefits Manage- bances of a Child;
ment Program and (3) the recipient of the trans-
plant is a Subscriber or Dependent. Benefits in- 2) hospitalization solely for X-ray, laboratory or
clude services incident to obtaining the human any other outpatient diagnostic studies or for
transplant material from a living donor or an organ medical observation;
transplant bank. 3) routine foot care items and services that are not
Failure to obtain prior written authorization and/or Medically Necessary, including callus, corn
failure to have the procedure performed at a con- paring or excision and toenail trimming except
tracting Special Transplant Facility will result in as may be provided through a Participating
denial of claims for this Benefit. Hospice Agency;over-the-counter shoe inserts
The following procedures are eligible for coverage or arch supports; or any type of massage pro-
under this provision: cedure on the foot;
4) home services, hospitalization or confinement
I) Human hear[transplants. in a health facility primarily for rest,Custodial,
2) Human lung transplants. Maintenance, or domiciliary care, except as
3) Human heart and lung transplants in combina-
provided under Hospice Program Benefits;
tion. 5) Continuous Nursing Services, private duty
4) Human kidney and pancreas transplants in nursing, or nursing shift care, except as pro-
combination. vided through a Participating Hospice Agency;
5) Human liver transplants. 6) prescription and non-prescription food and nu-
tritional supplements, except as provided un-
6) Human bone marrow transplants,including au- der Home Infusion and Home Injectable Ther-
tologous bone marrow transplantation apy Benefits, PKU Related Formulas and Spe-
(ABMT) or autologous peripheral stem cell cial Food Products Benefits, or as provided
transplantation used to support high-dose through a Participating Hospice Agency;
chemotherapy when such treatment is Medi-
cally Necessary and is not Experimental or In- 7) hearing aid instruments, examinations for the
vestigational. appropriate type of hearing aid, device checks,
electroacoustic evaluation for hearing aids and
7) Pediatric human small bowel transplants. other ancillary equipment unless Employer has
8) Pediatric and adult human small bowel and purchased hearing aids coverage as an optional
liver transplants in combination. Benefit, in which case an accompanying Sup-
plement provides the Benefit description;
42
8) eye exams and refractions, lenses and frames or when the proposed reconstructive surgery
for eyeglasses,contact lenses,except as specif- offers only a minimal improvement in the ap-
ically listed under Prosthetic Appliances Ben- pearance of the Member. This exclusion shall
efits, and video-assisted visual aids or video not apply to breast reconstruction when per-
magnification equipment for any purpose; formed subsequent to a mastectomy, including
9) surgery to correct refractive error (such as but surgery on either breast to achieve or restore
not limited to radial keratotomy,refractive ker- symmetry.
atoplasty); 15)sexual dysfunctions and sexual inadequacies,
10)any type of communicator, voice enhancer, except as provided for treatment of organically
voice prosthesis, electronic voice producing based conditions;
machine, or any other language assistive de- 16)any services related to assisted reproductive
vices, except as specifically listed under Pros- technology (including associated services such
thetic Appliances Benefits; as radiology, laboratory,medications, and pro-
11)for dental care or services incident to the treat- cedures) including but not limited to the har-
ment, prevention, or relief of pain or dysfunc- vesting or stimulation of the human ovum, in
tion of the Temporomandibular Joint and/or vitro fertilization, Gamete Intrafallopian
muscles of mastication, except as specifically Transfer (GIFT) procedure, Zygote Intrafal-
provided under the Medical Treatment of the lopian Transfer (ZIFT), Intracytoplasmic
Teeth, Gums, Jaw Joints or Jaw Bones Bene- sperm injection (ICSI), pre-implantation Be-
fits and Hospital Benefits (Facility Services); netic screening,donor services or procurement
and storage of donor embryos, oocytes, ovar-
12)for or incident to services and supplies for ian tissue, or sperm, any type of artificial en-
treatment of the teeth and gums (except for tu- semination, services or medications to treat
mors, preparation of the Member's jaw for ra- low sperm count, services incident to or result-
diation therapy to treat cancer in the head or ing from procedures for a surrogate mother
neck, and dental and orthodontic services that who is otherwise not eligible for covered preg-
are an integral part of Reconstructive Surgery nancy and maternity care under a Blue Shield
for cleft palate procedures) and associated pe- Health Plan, or services incident to reversal of
riodontal structures, including but not limited surgical sterilization, except for Medically
to diagnostic, preventive, orthodontic and Necessary treatment of medical complications
other services such as dental cleaning, tooth of the reversal procedure;
whitening, X-rays, imaging, laboratory ser- 17)services incident to bariatric surgery services,
vices, topical fluoride treatment except when
used with radiation therapy to the oral cavity, except as specifically provided under Boriatric
fillings, and root canal treatment; treatment of Surgery Benefits;
periodontal disease or periodontal surgery for 18)home testing devices and monitoring equip-
inflammatory conditions; tooth extraction; ment except as specifically provided in the
dental implants, braces, crowns, dental or- Durable Medical Equipment Benefits;
thoses and prostheses; except as specifically 19)genetic testing except as described in the Out-
provided under Medical Treatment of the patient X-ray, Pathology and Laboratory Ben-
Teeth, Gums, Jaw Joints or Jaw Bones Bene- efits;
fits and Hospital Benefits (Facility Services);
13)cosmetic Surgery except for Medically Neces- 20)mammographies, Pap Tests or other FDA
(Food and Drug Administration)approved cer-
sary treatment of resulting complications (e.g.,
infections hemorrhages); vical cancer screening tests, family planning
and consultation services, colorectal cancer
14)reconstructive Surgery where there is another screenings, Annual Health Appraisal Exams
more appropriate covered surgical procedure by Non-Participating Providers;
43
21)services performed in a Hospital by house of- for Treatment of Cancer or Life-Threatening
ficers, residents, interns, and other profession- Condition Benefits;
als in training without the supervision of an at- 28)drugs,medicines, supplements,tests,vaccines,
tending physician in association with an ac- devices, radioactive materials and any other
credited clinical education program; services which cannot be lawfully marketed
22)services performed by a Close Relative or by a without approval of the U.S. Food and Drug
person who ordinarily resides in the Member's Administration (the FDA) except as otherwise
home; stated; however, drugs and medicines which
23)services(except for services received under the have received FDA approval for marketing for
Behavioral Health Treatment benefit under one or more uses will not be denied on the ba-
Mental Health and Substance Use Disorder sis that they are being prescribed for an off-la-
Benefits) provided by an individual or entity bel use if the conditions set forth in California
that: Health & Safety Code, Section 1367.21 have
been met;
• is not appropriately licensed or certified by 29)non-prescription (over-the-counter) medical
the state to provide health care services; equipment or supplies such as oxygen satura-
• is not operating within the scope of such li- tion monitors, prophylactic knee braces and
cense or certification; or bath chairs that can be purchased without a li-
• does not maintain the Clinical Laboratory censed provider's prescription order, even if a
Improvement Amendments certificate re- licensed provider writes a prescription order
quired to perform the laboratory testing for a non-prescription item, except as specifi-
cally provided under Preventive Health Bene-
fits, Home Health Care Benefits, Home Infu-
24)massage therapy that is not Physical Therapy sion and Home Injectable Therapy Benefits,
or a component of a multimodality Rehabilita- Hospice Program Benefits, Diabetes Care
tive Services treatment plan; Benefits, Durable Medical Equipment Bene-
25)for or incident to vocational, educational, fits, and Prosthetic Appliances Benefits;
recreational, art, dance, music or reading ther- 30)patient convenience items such as telephone,
apy; weight control programs; exercise pro- television, guest trays, and personal hygiene
grams;nutritional counseling except as specifi- items;
cally provided for under Diabetes Care Bene- 31)disposable supplies for home use, such as ban-
fits or Preventive Health Services. This exclu- dages, gauze, tape, antiseptics, dressings, Ace-
sion shall not apply to Medically Necessary
services which Blue Shield is required by law type bandages, and diapers, underpads and
to cover for Severe Mental Illnesses or Serious other incontinence supplies, except as specifi-
Emotional Disturbances of a Child; cally provided under the Durable Medical
Equipment Benefits, Home Health Care, Hos-
26)learning disabilities or behavioral problems or pice Program Benefits, or the Outpatient Pre-
social skills training/therapy, or for testing for scription Drug Benefits Supplement.
intelligence or learning disabilities.This exclu- 32)services for which the Member is not legally
sion shall not apply to Medically Necessary obligated to pay, or for services for which no
services which Blue Shield is required by law charge is made;
to cover for Severe Mental Illnesses or Serious
Emotional Disturbances of a Child; 33)services incident to any injury or disease aris-
27)services which are Experimental or Investiga- ing out of, or in the course of, any employment
tional in nature except for services for Mem- for salary, wage or profit if such injury or dis-
bers who have been accepted into an approved ease is covered by any worker's compensation
clinical trial as provided under Clinical Trial law, occupational disease law or similar legis-
44
lation. However, if Blue Shield provides pay- c. When the Member is eligible for Medicare
ment for such services, it will be entitled to es- solely due to end stage renal disease during
tablish a lien upon such other benefits up to the the first 30 months that you are eligible to
amount paid by Blue Shield for the treatment receive benefits for end-stage renal disease
of such injury or disease; from Medicare.
34)drug's dispensed by a Physician or Physician's 2) Blue Shield will provide Benefits after Medi-
office for outpatient use; and care in the following situations:
35)transportation by car, taxi, bus, gurney van, a. When the Member is eligible for Medicare
wheelchair van, and any other type of trans- due to age, if the subscriber is actively
portation (other than a licensed ambulance or working for a group that employs less than
psychiatric transport van). 20 employees (as defined by Medicare
See the Grievance Process section for information Secondary Payer laws).
on filing a grievance, your right to seek assistance b. When the Member is eligible for Medicare
from the Department of Managed Health Care,and due to disability, if the subscriber is cov-
your right to independent medical review. ered by a group that employs less than 100
employees (as defined by Medicare Sec-
Medical Necessity Exclusion ondary Payer laws).
The Benefits of this Health Plan are provided only c. When the Member is eligible for Medicare
for services that are Medically Necessary.Because solely due to end stage renal disease after
a Physician or other provider may prescribe,order, the first 30 months that you are eligible to
recommend, or approve a service or supply does receive benefits for end-stage renal disease
not, in itself, make it Medically Necessary even from Medicare.
though it is not specifically listed as an exclusion d. When the Member is retired and age 65
or limitation. Blue Shield reserves the right to re- years or older.
view all claims to determine if a service or supply
is Medically Necessary and may use the services When Blue Shield provides Benefits after Medi-
of Physician consultants, peer review committees care,the combined benefits from Medicare and the
of professional societies or Hospitals, and other Blue Shield group plan may be lower but will not
consultants to evaluate claims. exceed the Medicare allowed amount. The Blue
Shield group plan Deductible and copayments will
Limitation for Duplicate Coverage be waived.
Medicare Eligible Members Medi-Cal Eligible Members
1) Blue Shield will provide Benefits before Medi- Medi-Cal always provides benefits last.
care in the following situations: Qualified Veterans
a. When the Member is eligible for Medicare If the Member is a qualified veteran Blue Shield
due to age, if the subscriber is actively will pay the reasonable value or Blue Shield's AI-
working for a group that employs 20 or lowable Amount for Covered Services provided at
more employees (as defined by Medicare a Veterans Administration facility for a condition
Secondary Payer laws). that is not related to military service. If the Mem-
b. When the Member is eligible for Medicare ber is a qualified veteran who is not on active duty,
due to disability, if the subscriber is cov- Blue Shield will pay the reasonable value or Blue
ered by a group that employs 100 or more Shield's Allowable Amount for Covered Services
employees (as defined by Medicare Sec- provided at a Department of Defense facility,even
ondary Payer laws). if provided for conditions related to military ser-
vice.
45
Members Covered by Another Government cry extends only to the amount of Benefits it
Agency has paid or will pay the Member or the Mem-
If the Member is entitled to benefits under any ber's representatives. For purposes of this pro-
other federal or state governmental agency, or by vision, Member's representatives include, if
any municipality, county or other political subdi- applicable, the Member's heirs, administra-
vision, the combined benefits from that coverage tors, legal representatives,parents(if the Mem-
and this Blue Shield group Plan will equal, but not ber is a minor), successors or assignees. This is
exceed, what Blue Shield would have paid if the Blue Shields right of recovery.
Member was not eligible to receive benefits under 2) Blue Shield is entitled under its right of recov-
that coverage (based on the reasonable value or ery to be reimbursed for its Benefit payments
Blue Shield's Allowable Amount). even if the Member is not"made whole" for all
Contact Customer Service if you have any ques- of his or her damages in the recoveries that the
tions about how Blue Shield coordinates your Member receives. Blue Shield's right of recov-
group Plan Benefits in the above situations. ery is not subject to reduction for attorney's
fees and costs under the"common fund"or any
Exception for Other Coverage other doctrine.
Participating Providers may seek reimbursement 3) Blue Shield will not reduce its share of any re-
from other third party payers for the balance of covery unless, in the exercise of Blue Shield's
their reasonable charges for services rendered un- discretion, Blue Shield agrees in writing to a
der this Plan. reduction (1) because the Member does not re-
ceive the full amount of damages that the
Claims Review Member claimed or (2) because the Member
had to pay attorneys' fees.
Blue Shield reserves the right to review all claims
to determine if any exclusions or other limitations 4) The Member must cooperate in doing what is
apply. Blue Shield may use the services of Physi- reasonably necessary to assist Blue Shield with
cian consultants, peer review committees of pro- its right of recovery. The Member must not
fessional societies or Hospitals, and other consul- take any action that may prejudice Blue
tants to evaluate claims. Shields right of recovery.
If the Member does seek damages for his or her ill-
Reductions —Third Party Liability ness or injury, the Member must tell Blue Shield
If another person or entity,through an act or omis- promptly that the Member has made a claim
sion, causes a Member to suffer an injury or ill- against another party for a condition that Blue
ness and if Blue Shield paid Benefits for that in- Shield has paid or may pay Benefits for,the Mem-
jury or illness, the Member must agree to the pro- ber must seek recovery of Blue Shield's Benefit
visions listed below. In addition, if the Member is payments and liabilities, and the Member must tell
injured and no other person is responsible but the us about any recoveries the Member obtains,
Member receives(or is entitled to)a recovery from whether in or out of court. Blue Shield may seek a
another source,and if Blue Shield paid Benefits for first priority lien on the proceeds of the Member's
that injury, the Member must agree to the follow- claim in order to reimburse Blue Shield to the full
ing provisions. amount of Benefits Blue Shield has paid or will
pay. The amount Blue Shield seeks as restitution,
1) All recoveries the Member or his or her repre- reimbursement or other available remedy will be
sentatives obtain (whether by lawsuit, settle- calculated in accordance with California Civil
ment, insurance or otherwise), no matter how Code Section 3040.
described or designated, must be used to reim-
burse Blue Shield in full for Benefits Blue Blue Shield may request that the Member sign a
Shield paid. Blue Shield's share of any recov- reimbursement agreement consistent with this pro-
vision.
46
Further, if the Member receives services from a benefit payments between two group Health Plans.
Participating Hospital for such injuries or illness, The following is a summary of those rules.
the Hospital has the right to collect from the Mem- 1) When a plan does not have a coordination of
ber the difference between the amount paid by benefits provision, that plan will always pro-
Blue Shield and the Hospital's reasonable and nec- vide its benefits first. Otherwise, the plan cov-
essary charges for such services when payment or ering the Member as an employee will provide
reimbursement is received by the Member for its benefits before the plan covering the Mem-
medical expenses. The Hospital's right to collect ber as a Dependent.
shall be in accordance with California Civil Code
Section 3045.1. 2) Coverage for dependent children:
IF THIS PLAN IS PART OF AN EMPLOYEE a. When the parents are not divorced or sepa-
WELFARE BENEFIT PLAN SUBJECT TO THE rated, the plan of the parent whose date of
EMPLOYEE RETIREMENT INCOME SECU- birth (month and day) occurs earlier in the
RITY ACT OF 1974 ("ERISA"), THE MEMBER year is primary.
IS ALSO REQUIRED TO DO THE FOLLOW- b. When the parents are divorced and the spe-
ING: cific terms of the court decree state that one
1) Ensure that any recovery is kept separate from of the parents is responsible for the health
and not comingled with any other funds or the care expenses of the child, the plan of the
Member's general assets and agree in writing responsible parent is primary.
that the portion of any recovery required to sat- c. When the parents are divorced or sepa-
isfy the lien or other right of recovery of Blue rated,there is no court decree, and the par-
Shield is held in trust for the sole benefit of ent with custody has not remarried, the
Blue Shield until such time it is conveyed to plan of the custodial parent is primary.
Blue Shield;
d. When the parents are divorced or sepa-
l) Direct any legal counsel retained by the Mem- rated, there is no court decree, and the par-
ber or any other person acting on behalf of the ent with custody has remarried,the order of
Member to hold that portion of the recovery to payment is as follows:
which Blue Shield is entitled in trust for the
sole benefit of Blue Shield and to comply with i. The plan of the custodial parent
and facilitate the reimbursement to Blue Shield ii. The plan of the stepparent
of the monies owed.
iii. The plan of the non-custodial parent.
Coordination of Benefits 3) If the above rules do not apply,the plan which
Coordination of Benefits is utilized when a Mem- has covered the Member for the longer period
ber is covered by more than one group Health Plan. of time is the primary plan. There may be ex-
Payments for allowable expenses will be coordi- ceptions for laid-off or retired employees.
nated between the two plans up to the maximum 4) When Blue Shield is the primary plan, Bene-
benefit amount payable by each plan separately. fits will be provided without considering the
Coordination of Benefits ensures that benefits paid other group Health Plan. When Blue Shield is
by multiple group Health Plans do not exceed the secondary plan and there is a dispute as to
100% of allowable expenses. The coordination of which plan is primary, or the primary plan has
benefits rules also provide consistency in deter- not paid within a reasonable period of time,
mining which group Health Plan is primary and Blue Shield will provide Benefits as if it were
avoid delays in benefit payments. Blue Shield fol- the primary plan.
lows the rules for Coordination of Benefits as out- 5) Anytime Blue Shield makes payments over the
lined in the California Code of Regulations, Title amount they should have paid as the primary
28, Section 1300.67.13 to determine the order of or secondary plan, Blue Shield reserves the
47
right to recover the excess payments from the may be enrolled as a Dependent of both parents.
other plan or any person to whom such pay- Please contact Blue Shield to determine what evi-
ments were made. dence needs to be provided to enroll a child.
These Coordination of Benefits rules do not apply Enrolled disabled Dependent children who would
to the programs included in the Limitation for Du- normally lose their eligibility under this Health
plicate Coverage section. Plan solely because of age,may be eligible for cov-
erage if they continue to meet the definition of De-
Conditions of Coverage pendent. See the Definitions section.
The Employer must meet specified Employer eli-
Eligibility and Enrollment gibility, participation and contribution require-
To enroll and continue enrollment, a Subscriber ments to be eligible for this group Health Plan. If
must be an eligible Employee and meet all of the the Employer fails to meet these requirements,this
eligibility requirements for coverage established coveragq will terminate. See the Termination of
by the Employer.An Employee is eligible for cov- Benefits section of this EOC for further informa-
erage as a Subscriber the day following the date he tion. Employees will receive notice of this termi-
or she completes the waiting period established by nation and, at that time, will be provided with in-
the Employer. The Employee's spouse or Domes- formation about other potential sources of cover-
tic Partner and all Dependent children are eligible age, including access to individual coverage
for coverage at the same time. through Covered California.
An Employee or the Employee's Dependents may Subject to the requirements described under the
enroll when initially eligible or during the Em- Continuation of Group Coverage provision in this
ployer's annual Open Enrollment Period. Under EOC, if applicable, an Employee and his or her
certain circumstances, an Employee and Depen- Dependents will be eligible to continue group cov-
dents may qualify for a Special Enrollment Period. erage under this Health Plan when coverage would
Other than the initial opportunity to enroll, a date otherwise terminate.
12 months from the date a written request for en-
rollment is made,the Employer's annual Open En-
Effective Date of Coverage
rollment period,or a Special Enrollment Period,an Blue Shield will notify the eligible Employee/Sub-
Employee or Dependent may not enroll in the scriber of the effective date of coverage for the
health program offered by the Employer. Please Employee and his or her Dependents. Coverage
see the definition of Late Enrollee and Special En- starts at 12:01 a.m. Pacific Time on the effective
rollment Period in the Definitions section for de- date.
tails on these rights. For additional information on Dependents may be enrolled within 31 days of the
enrollment periods,please contact the Employer or Employee's eligibility date to have the same effec-
Blue Shield. tive date of coverage as the Employee. If the Em-
Dependent children of the Subscriber, spouse, or ployee or Dependent is considered a Late Enrollee,
his or her Domestic Partner, including children coverage will become effective the earlier of 12
adopted or placed for adoption,will be covered im- months from the date a written request for cover-
mediately after birth, adoption or the placement of age is made or at the Employer's next Open En-
adoption for a period of 31 days. In order to have rollment Period. Blue Shield will not consider ap-
coverage continue beyond the first 31 days, an ap- plications for earlier effective dates unless the Em-
plication must be received by Blue Shield within ployee or Dependent qualifies for a Special Enroll-
31 days from the date of birth, adoption or place- ment Period.
ment for adoption. If both partners in a marriage or In general, if the Employee or Dependents qualify
Domestic Partnership are eligible Employees and for a Special Enrollment Period coverage will be-
Subscribers,then they are both eligible for Depen- gin no later than the first day of the first calendar
dent benefits. Their children may be eligible and
48
month after Blue Shield receives the request for Out-of-Pocket Maximum amounts, are subject to
special enrollment from the Employer. change at any time. Blue Shield will provide at
However, if the Employee qualifies for a Special least 60 days written notice of any such change.
Enrollment Period as a result of a birth, adoption, Benefits for services or supplies furnished on or af-
guardianship, marriage or Domestic Partnership ter the effective date of any change in Benefits will
and enrollment is requested by the Employee be provided based on the change.
within 31 days of the event, the effective date of
enrollment will be as follows: Renewal of the Group Health Service
1) For the case of a birth, adoption,placement for Contract
adoption, or guardianship, the coverage shall This Contract has a 12-month term beginning with
be effective on the date of birth, adoption, the eligible Employer's effective date of coverage.
placement for adoption or court order of So long as the Employer continues to qualify for
guardianship. this Health Plan and continues to offer this plan to
2) For marriage or Domestic Partnership the cov- its Employees, Employees and Dependents will
erage effective date shall be the first day of the have an annual Open Enrollment period of 30 days
month following the date the request for spe- before the end of the term to make changes to their
cial enrollment is received. coverage.The Employer will give notice of the an-
nual Open Enrollment period.
Premiums (Dues) Blue Shield will offer to renew the Employer's
The monthly Premiums for a Subscriber and any Group Health Service Contract except in the fol-
enrolled Dependents are stated in the Contract. lowing instances:
Blue Shield will provide the Employer with infor- 1) non-payment of Premium;
mation regarding when the Premiums are due and
when payments must be made for coverage to re- 2) fraud,or intentional misrepresentation of a ma-
main in effect. terial fact;
All Premiums required for coverage for the Sub- 3) failure to comply with Blue Shield's applica-
scriber and Dependents will be paid by the Em- ble eligibility, participation or contribution
ployer to Blue Shield. Any amount the Subscriber rules;
must contribute is set by the Employer. The Em- 4) termination of plan type by Blue Shield;
ployer will receive notice of changes in Premiums 5) Employer relocates outside of California; or
at least 60 days prior to the change. The Employer
will notify the Subscriber immediately. 6) Employer is an association and association
membership ceases.
Grace Period
After payment of the first Premium, the Contrac- Termination of Benefits (Cancellation
tholder is entitled to a grace period of 30 days for and Rescission of Coverage)
the payment of any Premiums due. During this Except as specifically provided under the Exten-
grace period, the Contract will remain in force. sion of Benefits provision, and, if applicable, the
However, the Contractholder will be liable for Continuation of Group Coverage provision, there
payment of Premiums accruing during the period is no right to receive Benefits of this Health Plan
the Contract continues in force. following termination of a Member's coverage.
Plan Changes Cancellation at Member Request
The Benefits and terms of this Health Plan, includ- If the Subscriber is making any contribution to-
ing but not limited to, Covered Services, De- Wards coverage for himself or herself, or for De-
ductible, Copayment, Coinsurance and annual pendents, the Subscriber may request termination
49
of this coverage. If coverage is terminated at the tive upon receipt,or on a later date as may be spec-
Subscriber's request, coverage will end at 11:59 ified by the notice.
p.m. Pacific Time on the last date for which Pre- Cancellation for Employer's Non-Payment of
miums have been paid. Premiums
Cancellation of Member's Enrollment by Blue Blue Shield may cancel this Health Plan for non-
Shield payment of Premiums. If the Employer fails to pay
Blue Shield may cancel the Subscriber and any the required Premiums when due, coverage will
Dependent's coverage for cause for the following terminate upon expiration of the 30-day grace pe-
conduct; cancellation is effective immediately riod following notice of termination for nonpay-
upon giving written notice to the Subscriber and ment of premium. The Employer will be liable for
Employer: all Premium accrued while this coverage continues
1) Providing false or misleading material infor- in force including those accrued during the grace
mation on the enrollment application or other- period. Blue Shield will mail the Employer a Can-
wise to the Employer or Blue Shield; see the cellation Notice (or Notice Confirming Termina-
Cancel lation/Rescission for Fraud, or Inten- tion of Coverage).The Employer must provide en-
tional Misrepresentations of Material Fact pro- rolled Employees with a copy of the Notice Con-
vision; firming Termination of Coverage.
2) Permitting use of a Member identification card Cancellation/Rescission for Fraud or
by someone other than the Subscriber or De- Intentional Misrepresentations of Material
pendents to obtain Covered Services; or Fact
3) Obtaining or attempting to obtain Covered Ser- Blue Shield may cancel or rescind the Contract for
vices under the Group Health Service Contract fraud or intentional misrepresentation of material
by means of false, materially misleading, or fact by the Employer, or with respect to coverage
fraudulent information, acts or omissions. of Employees or Dependents, for fraud or inten-
tional misrepresentation of material fact by the
If the Employer does not meet the applicable eligi- Employee, Dependent, or their representative. A
bility, participation and contribution requirements rescission voids the Contract retroactively as if it
of the Contract, Blue Shield will cancel this cover- was never effective; Blue Shield will provide writ-
age after 30 days' written notice to the Employer. ten notice to the Employer prior to any rescission.
Any Premiums paid to Blue Shield for a period ex- In the event the Contract is rescinded or cancelled,
tending beyond the cancellation date will be re- either by Blue Shield orthe Employer, it is the Em-
funded to the Employer. The Employer will be re- ployer's responsibility to notify each enrolled Em-
sponsible to Blue Shield for unpaid Premiums ployee of the rescission or cancellation. Cancella-
prior to the date of cancellation. tions are effective on receipt or on such later date
Blue Shield will honor all claims for Covered Ser- as specified in the cancellation notice.
vices provided prior to the effective date of cancel- If a Member is hospitalized or undergoing treat-
lation. ment for an ongoing condition and the Contract is
See the Cancellation/Rescission for Fraud or In- cancelled for any reason, including non-payment
tentional Misrepresentations of Material Fact sec- of Premium, no Benefits will be provided unless
tion. the Member obtains an Extension of Benefits. (See
the Extension of Benefits section for more informa-
Cancellation by the Employer tion.)
This Health Plan may be cancelled by the Em- Date Coverage Ends
ployer at any time provided written notice is given
to all Employees and Blue Shield to become effec- Coverage for a Subscriber and all of his or her De-
50
pendents ends at 11:59 p.m.Pacific Time on the ear- nia Family Rights Act of 1991 and/or the federal
liest of these dates: Family& Medical Leave Act of 1993, and the ap-
t) the date the Employer- Group Health Service proved leave of absence is for family leave under
Contract is discontinued; the terms of such Act(s), a Subscriber's payment
of Premiums will keep coverage in force for such
2) the last day of the month in which the Sub- period of time as specified in such Act(s).The Em-
scriber's employment terminates, unless a dif- ployer is solely responsible for notifying their Em-
ferent date has been agreed to between Blue ployee of the availability and duration of family
Shield and the Employer; leaves.
3) the date as indicated in the Notice Confirming Reinstatement
Termination of Coverage that is sent to the Em-
ployer (see Cancellation for Non-Payment of If the Subscriber had been making contributions
Premiums); or toward coverage for the Subscriber and Depen-
dents and voluntarily cancelled such coverage, he
4) the last day of the month in which the Sub- or she should contact Blue Shield or the Employer
scriber and Dependents become ineligible for regarding reinstatement options.If reinstatement is
coverage,except as provided below. not an option, the Subscriber may have a right to
Even if a Subscriber remains covered, his Depen- re-enroll if the Subscriber or Dependents qualify
dents' coverage may end if a Dependent become in- for a Special Enrollment Period (see Special En-
eligible. A Dependent spouse becomes ineligible rollment Periods in the Definitions section). The
following legal separation from the Subscriber, en- Subscriber or Dependents may also enroll during
try of a final decree of divorce, annulment or disso- the annual Open Enrollment Period. Enrollment
lution of marriage from the Subscriber; coverage resulting from a Special Enrollment Period or an-
ends on the last day of the month in which the De- nual Open Enrollment Period is not reinstatement
pendent spouse became ineligible. A Dependent and may result in a gap in coverage.
Domestic Partner becomes ineligible upon termina-
tion of the domestic partnership; coverage ends on Extension of Benefits
the last day of the month in which the Domestic If a Member becomes Totally Disabled while
Partner becomes ineligible.A Dependent child who validly covered under this health plan and contin-
reaches age 26 becomes ineligible on the last day of ues to be Totally Disabled on the date the Contract
the month in which his or her 261h birthday occurs, terminates, Blue Shield will extend Benefits, sub-
unless the Dependent child is disabled and qualifies ject to all limitations and restrictions, for Covered
for continued coverage as described in the defini- Services and supplies directly related to the condi-
tion of Dependent. tion, illness or injury causing such Total Disability
In addition, if a written application for the addition until the first to occur of the following: (1) twelve
of a newborn or a child placed for adoption is not months from the date coverage terminated; (2) the
submitted to and received by Blue Shield within date the covered Member is no longer Totally Dis-
the 31 days following that Dependent's birth or abled; or(3) the date on which a replacement car-
placement for adoption, Benefits under this Health rier provides coverage to the Member.
Plan for that child will end on the 31st day after the No extension will be granted unless Blue Shield
birth or placement for adoption at 11:59 p.m. Pa- receives written certification of such Total Disabil-
cific Time. ity from a Doctor of Medicine within 90 days of
If the Subscriber ceases work because of retire- the date on which coverage was terminated, and
ment, disability, leave of absence, temporary lay- thereafter at such reasonable intervals as deter-
off, or termination, he or she should contact the mined by Blue Shield.
Employer or Blue Shield for information on op-
tions for continued group coverage or individual
options. If the Employer is subject to the Califor-
51
Group Continuation Coverage b. the reduction of hours of employment to
less than the number of hours required for
Please examine group continuation coverage op- eligibility.
tions carefully before declining this coverage.
2) With respect to the Dependent spouse or De-
A Member can continue his or her coverage under pendent Domestic Partner and Dependent chil-
this group Health Plan when the Subscriber's Em- dren (children bom to or placed for adoption
ployer is subject to either Title X of the Consoli- with the Subscriber or Domestic Partner dur-
dated Omnibus Budget Reconciliation Act (CO- ing a COBRA or Cal-COBRA continuation pe-
BRA) as amended or the California Continuation riod may be immediately added as Dependents,
Benefits Replacement Act (Cal-COBRA). The provided the Contractholder is properly noti-
Subscriber's Employer should be contacted for fied of the birth or placement for adoption, and
more information. such children are enrolled within 30 days of the
In accordance with the Consolidated Omnibus birth or placement for adoption):
Budget Reconciliation Act (COBRA) as amended a. the death of the Subscriber;
and the California Continuation Benefits Replace-
ment Act (Cal-COBRA), a Member may elect to b. the termination of the Subscriber's em-
continue group coverage under this Plan if the ployment (other than by reason of such
Member would otherwise lose coverage because Subscriber's gross misconduct);
of a Qualifying Event that occurs while the Con- c. the reduction of the Subscriber's hours of
tractholder is subject to the continuation of group employment to less than the number of
coverage provisions of COBRA or Cal-COBRA. hours required for eligibility;
The benefits under the group continuation of cov-
erage will be identical to the benefits that would be d. the divorce or legal separation of the Sub-
provided to the Member if the Qualifying Event scriber from the Dependent spouse or ter-
had not occurred (including any changes in such mination of the domestic partnership;
coverage). e. the Subscriber's entitlement to benefits un-
A Member will not be entitled to benefits under der Title XVIII of the Social Security Act
Cal-COBRA if at the time of the qualifying event ("Medicare"); or
such Member is entitled to benefits under Title f. a Dependent child's loss of Dependent sta-
XVIII of the Social Security Act ("Medicare") or tus under this Plan.
is covered under another group health plan. Under Domestic Partners and Dependent children of
COBRA, a Member is entitled to benefits if at the Domestic Partners cannot elect COBRA on
time of the qualifying event such Member is enti- their own, and are only eligible for COBRA if
tled to Medicare or has coverage under another the Subscriber elects to enroll. Domestic Part-
group health plan. However, if Medicare entitle- ners and Dependent children of Domestic Part-
ment or coverage under another group health plan ners may elect to enroll in Cal-COBRA on
arises after COBRA coverage begins, it will cease. their own.
Qualifying Event 3) For COBRA only,with respect to a Subscriber
A Qualifying Event is defined as a loss of cover- who is covered as a retiree, that retiree's De-
age as a result of any one of the following occur- pendent spouse and Dependent children, the
rences. Employer's filing for reorganization under Ti-
t) With respect to the Subscriber: tle XI, United States Code, commencing on or
after July 1, 1986.
a. the termination of employment(other than
by reason of gross misconduct); or 4) With respect to any of the above, such other
Qualifying Event as may be added to Title X
52
of COBRA or the California Continuation ing Event. Failure to provide such notice
Benefits Replacement Act (Cal-COBRA). within 60 days will disqualify the Member
Notification of a Qualifying Event from receiving continuation coverage under
Cal-COBRA.
1) With respect to COBRA enrollees: The Employer is responsible for notifying Blue
The Member is responsible for notifying the Shield in writing of the Subscriber's termina-
Employer of divorce, legal separation, or a tion or reduction of hours of employment
child's loss of Dependent status under this within 30 days of the Qualifying Event.
Plan, within 60 days of the date of the later of When Blue Shield is notified that a Qualifying
the Qualifying Event or the date on which cov-
erage would otherwise terminate under this Event has occurred,Blue Shield will,within 14
Plan because of a Qualifying Event. days, provide written notice the Member by
first class mail of his or her r right to continue
The Employer is responsible for notifying its group coverage under this Plan. The Member
COBRA administrator(or plan administrator if must then give Blue Shield notice in writing of
the Employer does not have a COBRA admin- the Member's election of continuation cover-
istrator)of the Subscriber's death,termination, age within 60 days of the later of(1) the date
or reduction of hours of employment, the Sub- of the notice of the Member's right to continue
scriber's Medicare entitlement or the Em- group coverage or (2) the date coverage termi-
ployer's filing for reorganization under Title nates due to the Qualifying Event. The written
XI, United States Code. election notice must be delivered to Blue
When the COBRA administrator is notified Shield by first-class mail or other reliable
that a Qualifying Event has occurred, the CO- means.
BRA administrator will, within 14 days, pro- If the Member does not notify Blue Shield
vide written notice to the Member by first class within 60 days, the Member's coverage will
mail of the Member's right to continue group terminate on the date the Member would have
coverage under this, Plan. The Member must lost coverage because of the Qualifying Event.
then notify the COBRA administrator within
60 days of the later of(1)the date of the notice w this Plan replaces a previous group plan that
as in effect with the Employer, and the Mem-
of the Member's right to continue group cov-
erage or (2) the date coverage terminates due ber had elected Cal-COBRA continuation cov-
to the Qualifying Event. erage under the previous plan, the Member
may choose to continue to be covered by this
If the Member does not notify the COBRA ad- Plan for the balance of the period that the
ministrator within 60 days, the Member's cov- Member could have continued to be covered
erage will terminate on the date the Member under the previous plan, provided that the
would have lost coverage because of the Quali- Member notify Blue Shield within 30 days of
fying Event. receiving notice of the termination of the pre-
2) With respect to Cal-COBRA enrollees: vious group plan.
The Member is responsible for notifying Blue Duration and Extension of Group Continuation
Shield in writing of the Subscriber's death or Coverage
Medicare entitlement, of divorce, legal separa- Cal-COBRA enrollees will be eligible to continue
tion,termination of a domestic partnership or a Cal-COBRA coverage under this Plan for up to a
child's loss of Dependent status under this maximum of 36 months regardless of the type of
Plan. Such notice must be given within 60 days Qualifying Event.
of the date of the later of the Qualifying Event COBRA enrollees who reach the 18-month or 29-
or the date on which coverage would otherwise month maximum available under COBRA, may
terminate under this Plan because of a Qualify-
elect to continue coverage under Cal-COBRA for
53
a maximum period of 36 months from the date the months because of a Social Security disability de-
Member's continuation coverage began under CO- termination, Premiums for Cal-COBRA coverage
BRA. If elected, the Cal-COBRA coverage will shall be 110 percent of the applicable group Pre-
begin after the COBRA coverage ends. mium rate for months 30 through 36.
Note: COBRA enrollees must exhaust all the CO- If the Member is enrolled in COBRA and is con-
BRA coverage to which they are entitled before tributing to the cost of coverage, the Employer
they can become eligible to continue coverage un- shall be responsible for collecting and submitting
der Cal-COBRA. all Premium contributions to Blue Shield in the
In no event will continuation of group coverage manner and for the period established under this
under COBRA, Cal-COBRA or a combination of Plan.
COBRA and Cal-COBRA be extended for more Cal-COBRA enrollees must submit Premiums di-
than 3 years from the date the Qualifying Event has rectly to Blue Shield. The initial Premiums must
occurred which originally entitled the Member to be paid within 45 days of the date the Member pro-
continue group coverage under this Plan. vided written notification to Blue Shield of the
Note: Domestic Partners and Dependent children election to continue coverage and be sent to Blue
of Domestic Partners cannot elect COBRA on their Shield by first-class mail or other reliable means.
own, and are only eligible for COBRA if the Sub- The Premium payment must equal an amount suf-
scriber elects to enroll. Domestic Partners and De- ficient to pay any required amounts that are due.
pendent children of Domestic Partners may elect Failure to submit the correct amount within the 45-
to enroll in Cal-COBRA on their own. day period will disqualify the Member from con-
tinuation coverage.
Notification Requirements Effective Date of the Continuation of Coverage
The Employer or its COBRA administrator is re-
sponsible for notifying COBRA enrollees of their The continuation of coverage will begin on the
right to possibly continue coverage under Cal-CO- date the Member's coverage under this Plan would
BRA at least 90 calendar days before their CO- otherwise terminate due to the occurrence of a
BRA coverage will end. The COBRA enrollee Qualifying Event and it will continue for up to the
should contact Blue Shield for more information applicable period, provided that coverage is timely
about continuation of coverage under Cal-CO- elected and so long as Premiums are timely paid.
BRA.If the enrollee is eligible and chooses to con- Termination of Group Continuation Coverage
tinue coverage under Cal-COBRA, the enrollee The continuation of group coverage will cease if
must notify Blue Shield of their Cal-COBRA elec- any one of the following events occurs prior to the
tion at least 30 days before COBRA termination. expiration of the applicable period of continuation
Payment of Premiums (Dues) of group coverage:
Premiums for the Member continuing coverage 1) discontinuance of this group health service
shall be 102 percent of the applicable group Pre- contract (if the Employer continues to provide
mium rate if the Member is a COBRA enrollee, or any group benefit plan for employees, the
110 percent of the applicable group Premium rate Member may be able to continue coverage
if the Member is a Cal-COBRA enrollee, except with another plan);
for the Member who is eligible to continue group 2) failure to timely and fully pay the amount of
coverage to 29 months because of a Social Secu- required Premiums to the COBRA administra-
rity disability determination, in which case, the for or the Employer or to Blue Shield as appli-
Premiums for months 19 through 29 shall be 150 cable. Coverage will end as of the end of the
percent of the applicable group Premium rate. period for which Premiums were paid;
Note: For COBRA enrollees who are eligible to 3) the Member becomes covered under another
extend group coverage under COBRA to 29
group health plan;
54
4) the Member becomes entitled to Medicare; When a Benefit specifies a Benefit maximum and
5) the Member commits fraud or deception in the that Benefit maximum has been reached,the Mem-
use of the services of this Plan. ber is responsible for any charges above the Bene-
fit-maximums.
Continuation of group coverage in accordance
with COBRA or Cal-COBRA will not be termi- Right of Recovery
nated except as described in this provision. In no
event will coverage extend beyond 36 months. Whenever payment on a claim has been made in
error, Blue Shield will have the right to recover
Continuation of Group Coverage such payment from the Subscriber or Member or,
for Members on Military Leave if applicable, the provider or another health bene-
Continuation of group coverage is available for fit plan, in accordance with applicable laws and
Members on military leave if the Member's Em- regulations. Blue Shield reserves the right to
ployer is subject to the Uniformed Services Em- deduct or offset any amounts paid in error from
ployment and Re-employment Rights Act any pending or future claim to the extent permitted
(USERRA). Members who are planning to enter by law. Circumstances that might result in pay-
the Armed Forces should contact their Employer ment of a claim in error include, but are not lim-
for information about their rights under the ited to, payment of benefits in excess of the bene-
(USERRA). Employers are responsible to ensure fits provided by the health plan, payment of
compliance with this act and other state and fed- amounts that are the responsibility of the Sub-
eral laws regarding leaves of absence including the scriber or Member(deductibles,copayments,coin-
California Family Rights Act, the Family and surance or similar charges), payment of amounts
Medical Leave Act, Labor Code requirements for that are the responsibility of another payor, pay-
Medical Disability. ments made after termination of the Subscriber or
Member's eligibility, or payments on fraudulent
General Provisions claims.
Liability of Subscribers in the Event No Lifetime Benefit Maximum
of Non-Payment by Blue Shield There is no maximum limit on the aggregate pay-
ments made by Blue Shield for Covered Services
In accordance with Blue Shield's established poli- provided under the Contract and this Health Plan.
cies, and by statute, every contract between Blue
Shield and its Participating Providers stipulates No Annual Dollar Limits on Essential
that the Subscriber shall not be responsible to the Health Benefits
Participating Provider for compensation for any
services to the extent that they are provided in the This Health Plan contains no annual dollar limits
Member's Group Contract.Participating Providers on essential health benefits as defined by federal
have agreed to accept the Blue Shield's payment law.
as payment-in-full for Covered Services, except
for Deductibles, Copayments and Coinsurance, Independent Contractors
and amounts in excess of specified Benefit maxi- Providers are neither agents nor employees of Blue
mums, or as provided under the Exception for Shield but are independent contractors. In no in-
Other Coverage and Reductions-Third Party Lia- stance shall Blue Shield be liable for the negli-
bility sections. gence, wrongful acts, or omissions of any person
If services are provided by a Non-Participating receiving or providing services, including any
Provider, the Member is responsible for all Physician, Hospital, or other provider or their em-
amounts Blue Shield does not pay. ployees.
55
Non-Assignability terests in Blue Shield. The names of the members
of the Board of Directors may be obtained from:
Coverage or any Benefits of this Plan may not be
assigned without the written consent of Blue Sr. Manager, Regulatory Filings
Shield. Possession of a Blue Shield ID card con- Blue Shield of California
fers no right to Covered Services or other Benefits 601 121h Street
of this Plan. To be entitled to services, the Mem- Oakland, CA 94607
ber must be a Subscriber or Dependent who has Phone: 1-510-607-2065
been accepted by the Employer and enrolled by Please follow the following procedure:
Blue Shield and who has maintained enrollment
under the terms of this Contract. 1) Recommendations, suggestions or comments
should be submitted in writing to the Sr. Man-
Participating Providers are paid directly by Blue ager, Regulatory Filings, at the above address,
Shield. who will acknowledge receipt of your letter.
If the Member receives services from a Non-Par- 2) Please include name, address, phone number,
ticipating Provider, payment will be made directly Subscriber number, and group number with
to the Subscriber, and the Subscriber is responsi- each communication.
ble for payment to the Non-Participating Provider.
The Member or the provider of service may not re- 3) The public policy issue should be stated so that
quest that the payment be made directly to the it will be readily understood. Submit all rele-
provider of service. vant information and reasons for the policy is-
sue with your letter.
Plan Interpretation 4) Public policy issues will be heard at least guar-
Blue Shield shall have the power and authority to terly as agenda items for meetings of the Board
construe and interpret the provisions of this Plan, of Directors. Minutes of Board meetings will
to determine the Benefits of this Plan and deter- reflect decisions on public policy issues that
mine eligibility to receive Benefits under this Plan. were considered. Members who have initiated
Blue Shield shall exercise this authority for the a public policy issue will be furnished with the
benefit of all Members entitled to receive Benefits appropriate extracts of the minutes within 10
under this Plan. business days after the minutes have been ap-
proved.
Public Policy Participation Procedure Confidentiality of Personal and Health
This procedure enables Members to participate in Information
establishing the public policy of Blue Shield. It is Blue Shield protects the privacy of individually
not to be used as a substitute for the grievance pro- identifiable personal information, including Pro-
cedure, complaints, inquiries or requests for infor- tected Health Information. Individually identifi-
mation. able personal information includes health, finan-
Public policy means acts performed by a plan or its cial, and/or demographic information such as
employees and staff to assure the comfort, dignity, name, address, and social security number. Blue
and convenience of patients who rely on the plan's Shield will not disclose this information without
facilities to provide health care services to them, authorization, except as permitted or required by
their families, and the public (California Health law.
and Safety Code, §1369). A STATEMENT DESCRIBING BLUE
At least one third of the Board of Directors of Blue SHIELD'S POLICIES AND PROCEDURES FOR
Shield is comprised of Subscribers who are not PRESERVING THE CONFIDENTIALITY OF
employees, providers, subcontractors or group MEDICAL RECORDS IS AVAILABLE AND
contract brokers and who do not have financial in-
56
WILL BE FURNISHED TO YOU UPON RE- Medical Services
QUEST.
The Member, a designated representative, or a
Blue Shield's"Notice of Privacy Practices" can be provider on behalf of the Member, may contact the
obtained either by calling Customer Service at the Customer Service Department by telephone, letter,
number listed in the back of this EOC, or by ac- or online to request a review of an initial determi-
cessing Blue Shield's internet site at nation concerning a claim or service. Members
www.blueshieldca.com and printing a copy. may contact Blue Shield at the telephone number
Members who are concerned that Blue Shield may as noted on the back page of this EOC. If the tele-
have violated their privacy rights, or who disagree phone inquiry to Customer Service does not re-
with a decision Blue Shield made about access to solve the question or issue to the Member's satis-
their individually identifiable personal informa- faction, the Member may request a grievance at
tion, may contact Blue Shield at: that time, which the Customer Service Represen-
Correspondence Address: tative will initiate on the Member's behalf.
Blue Shield of California Privacy Office The Member, a designated representative, or a
P.O. Box 272540 provider on behalf of the Member may also initi-
Chico 95927-2540 ate a grievance by submitting a letter or a com-
pleted "Grievance Form". The Member may re-
quest this Form from Customer Service. The com-
Access to Information pleted form should be submitted to Customer Ser-
Blue Shield may need information from medical vice Appeals and Grievance, P.O. Box 5588, El
Dorado Hills, CA 95762-0011. The Member may
providers, from other carriers or other entities, or also submit the grievance online by visiting
from the Member, in order to administer the Ben- www.blueshieldca.com.
efits and eligibility provisions of this Contract. By
enrolling in this Health Plan, each Member agrees For all grievances except denial of coverage for
that any provider or entity can disclose to Blue a Non-Formulary Drug: Blue Shield will ac-
Shield that information that is reasonably needed knowledge receipt of a grievance within five cal-
by Blue Shield. Members also agree to assist Blue endar days. Grievances are resolved within 30
Shield in obtaining this information, if needed,(in- days.
cluding signing any necessary authorizations) and Members can request an expedited decision when
to cooperate by providing Blue Shield with infor- the routine decision making process might
mation in the Member's possession. seriously jeopardize the life or health of a Member,
Failure to assist Blue Shield in obtaining necessary or when the Member is experiencing severe pain.
information or refusal to provide information rea- Blue Shield shall make a decision and notify the
sonably needed may result in the delay or denial of Member and Physician as soon as possible to
Benefits until the necessary information is re- accommodate the Member's condition not to
ceived. Any information received for this purpose exceed 72 hours following the receipt of the
by Blue Shield will be maintained as confidential request. An expedited decision may involve
and will not be disclosed without consent, except admissions, continued stay, or other healthcare
as otherwise permitted by law. services. For additional information regarding the
expedited decision process, or to request an
Grievance Process expedited decision be made for a particular issue,
please contact Customer Service.
Blue Shield has established a grievance procedure For grievances due to denial of coverage for a
for receiving, resolving and tracking Members' Non-Formulary Drug: If your Employer selected
grievances with Blue Shield. the optional Outpatient Prescription Drug Benefits
Supplement as a Benefit and Blue Shield denies an
57
exception request for coverage of a Non- solved within 30 days. The grievance system al-
Formulary Drug, the Member, representative, or lows Subscribers to file grievances within 180
the Provider may submit a grievance requesting an days following any incident or action that is the
external exception request review.Blue Shield will subject of the Member's dissatisfaction. See the
ensure a decision within 72 hours in routine previous Customer Service section for information
circumstances or 24 hours in exigent on the expedited decision process.
circumstances. For additional information, please If the grievance involves an MHSA Non-Partici-
contact Customer Service. pating Provider, the Member should contact the
For all grievances: The grievance system allows Blue Shield Customer Service Department as
Subscribers to file grievances within 180 days shown on the back page of this EOC.
following any incident or action that is the subject Members can request an expedited decision when
of the Member's dissatisfaction. the routine decision making process might seri-
Mental Health and Substance Use ouslyjeopardize the life or health of a Member, or
Disorder Services when the Member is experiencing severe pain.The
MHSA shall make a decision and notify the Mem-
Members, a designated representative, or a ber and Physician as soon as possible to accommo-
provider on behalf of the Member may contact the date the Member's condition not to exceed 72
MHSA by telephone, letter, or online to request a hours following the receipt of the request. An ex-
review of an initial determination concerning a pedited decision may involve admissions, contin-
claim or service.Members may contact the MHSA ued stay, or other healthcare services. For addi-
at the telephone number provided below. If the tional information regarding the expedited deci-
telephone inquiry to the MHSA's Customer Ser- sion process,or to request an expedited decision be
vice Department does not resolve the question or made for a particular issue, please contact the
issue to the Member's satisfaction, the Member MHSA at the number listed above.
may submit a grievance at that time, which the PLEASE NOTE:If your Employer's health plan is
Customer Service Representative will initiate on governed by the Employee Retirement Income Se-
the Member's behalf. curity Act ("ERISA"), you may have the right to
bring a civil action under Section 502(a)of ERISA
The Member, a designated representative, or a if all required reviews of your claim have been
provider on behalf of the Member may also initi- completed and your claim has not been approved.
ate a grievance by submitting a letter or a com- Additionally, you and your plan may have other
pleted "Grievance Form". The Member may re- voluntary alternative dispute resolution options,
quest this Form from the MHSA's Customer Ser- such as mediation.
vice Department. If the Member wishes, the
MHSA's Customer Service staff will assist in External Independent Medical Review
completing the Grievance Form. Completed
Grievance Forms should be mailed to the MHSA For grievances involving claims or services for
at the address provided below. The Member may which coverage was denied by Blue Shield or by a
also submit the grievance to the MHSA online by contracting provider in whole or in part on the
visiting www.blueshieldca.com. grounds that the service is not Medically Neces-
sary or is experimental/investigational (including
1-877-263-9952 the external review available under the Friedman-
Blue Shield of California Knowles Experimental Treatment Act of 1996).
Mental Health Service Administrator Members may choose to make a request to the De-
P.O. Box 719002 partment of Managed Health Care to have the mat-
San Diego, CA 92171-9002 ter submitted to an independent agency for exter-
The MHSA will acknowledge receipt of a griev- nal review in accordance with California law.
ance within five calendar days. Grievances are re- Members normally must first submit a grievance
58
to Blue Shield and wait for at least 30 days before prohibit any potential legal rights or remedies that
requesting external review; however, if the matter may be available to you. If you need help with a
would qualify for an expedited decision as de- grievance involving an emergency, a grievance
scribed above or involves a determination that the that has not been satisfactorily resolved by your
requested service is experimental/investigational, health plan, or a grievance that has remained unre-
a Member may immediately request an external re- solved for more than 30 days,you may call the De-
view following receipt of notice of denial.A Mem- partment for assistance.
ber may initiate this review by completing an ap- you may also be eligible for an Independent Medi-
plication for external review, a copy of which can cal Review(IMR). If you are eligible for IMR,the
be obtained by contacting Customer Service. IMR process will provide an impartial review of
The Department of Managed Health Care will re- medical decisions made by a health plan related to
view the application and, if the request qualifies the Medical Necessity of a proposed service or
for external review, will select an external review treatment, coverage decisions for treatments that
agency and have the Member's records submitted are experimental or investigational in nature, and
to a qualified specialist for an independent deter- payment disputes for emergency or urgent medical
mination of whether the care is Medically Neces- services.
sary. Members may choose to submit additional The Department also has a toll-free telephone
records to the external review agency for review. number(1-888-466-2219) and a TDD line (1-877-
There is no cost to the Member for this external re- 688-9891) for the hearing and speech impaired.
view. The Member and the Member's physician The Department's internet website,
will receive copies of the opinions of the external (htta://www.dmhe.ca.sov), has complaint forms,
review agency.The decision of the external review IMR application forms, and instructions online.
agency is binding on Blue Shield; if the external
reviewer determines that the service is Medically In the event that Blue Shield should cancel or
Necessary, Blue Shield will promptly arrange for refuse to renew the enrollment for you or your De-
the service to be provided or the claim in dispute pendents and you feel that such action was due to
to be paid. reasons of health or utilization of benefits, you or
This external review process is in addition to any your Dependents may request a review by the De-
other procedures or remedies available and is com-
partment of Managed Health Care Director.
pletely voluntary;Members are not obligated to re-
quest external review. However, failure to partici- Customer Service
pate in external review may cause the Member to For questions about services, providers, Benefits,
give up any statutory right to pursue legal action how to use this Plan, or concerns regarding the
against Blue Shield regarding the disputed service. quality of care or access to care, contact Blue
For more information regarding the external re- Shield's Customer Service Department. Customer
view process, or to request an application form, Service can answer many questions over the tele-
please contact Customer Service. phone. Contact Information is provided on the last
Department of Managed Health Care page of this EOC.
Review For all Mental Health and Substance Use Disorder
Services Blue Shield has contracted with a Mental
The California Department of Managed Health Health Service Administrator (MHSA). The
Care is responsible for regulating health care ser- MESA should be contacted for questions about
vice plans. If you have a grievance against your Mental Health and Substance Use Disorder Ser-
health plan,you should first telephone your health vices, MESA Participating Providers, or Mental
plan at 1-888-256-1915 and use your health plan's Health and Substance Use Disorder Benefits.
grievance process before contacting the Depart- Members may contact the MHSA at the telephone
ment. Utilizing this grievance procedure does not number or address which appear below:
59
1-877-263-9952 a. Non-Participating dialysis center—for ser-
Blue Shield of California vices prior authorized by Blue Shield, the
Mental Health Service Administrator amount is the Reasonable and Customary
P.O. Box 719002 Charge.
San Diego, CA 92171-9002 4) For a provider outside of California (within or
outside of the United States), that has a con-
Definitions tract with the local Blue Cross and/or Blue
When the following terms are capitalized in this Shield Plan: the amount that the provider and
EOC, they will have the meaning set forth below: the local Blue Cross and/or Blue Shield Plan
have agreed by contract will be accepted as
Accidental Injury— a definite trauma, resulting payment in full for the Covered Service(s)ren-
from a sudden, unexpected and unplanned event, dered.
occurring by chance, and caused by an indepen-
dent, external source. 5) For a Non-Participating Provider outside of
California (within or outside of the United
Activities of Daily Living (ADL) — mobility States) that does not contract with a local Blue
skills required for independence in normal, every- Cross and/or Blue Shield Plan, who provides
day living. Recreational, leisure, or sports activi- services (other than Emergency Services): the
ties are not considered ADL. amount that the local Blue Cross and/or Blue
Allowable Amount (Allowance) — the total Shield Plan would have allowed for a non-par-
amount Blue Shield allows for Covered Service(s) ticipating provider performing the same ser-
rendered, or the provider's billed charge for those vices. Or, if the local Blue Cross and/or Blue
Covered Services, whichever is less. The Allow- Shield Plan has no non-participating provider
able Amount, unless specified for a particular ser- allowance, the Allowable Amount is the
vice elsewhere in this EOC, is: amount for a Non-Participating Provider in
California.
1) For a Participating Provider: the amount that
the provider and Blue Shield have agreed by Alternate Care Services Provider—refers to a
contract will be accepted as payment in full for supplier of Durable Medical Equipment, or a cer-
the Covered Service(s) rendered. tified orthotist, prosthetist, or prosthetist-orthotist.
2) For a Non-Participating Provider who provides Ambulatory Surgery Center — an outpatient
Emergency Services, anywhere within or out- surgery facility providing outpatient services
side of the United States: which:
a. Physicians and Hospitals —the amount is 1) is either licensed by the state of California as
the Reasonable and Customary Charge; or an ambulatory surgery center, or is a licensed
facility accredited by an ambulatory surgery
b. All other providers — the amount is the center accrediting body; and
provider's billed charge for Covered Ser-
vices, unless the provider and the local 2) provides services as a free-standing ambula-
Blue Cross and/or Blue Shield plan have tory surgery center, which is licensed sepa-
agreed upon some other amount. rately and bills separately from a Hospital, and
3) For allon-Participating Provider in California is not otherwise affiliated with a Hospital.
who provides services (other than Emergency ASH Participating Provider— a Physician or
Services): the amount Blue Shield would have Health Care Provider under contract with ASH
allowed for a Participating Provider perform- Plans to provide Covered Services to Members.
ing the same service in the same geographical Bariatric Surgery Services Provider—a Partic-
area; or ipating Hospital, Ambulatory Surgery Center, or a
Physician that has been designated by Blue Shield
60
to provide bariatric surgery services to Members Hospice Program. Continuous home care can be
who are residents of designated counties in Cali- provided by a registered or licensed vocational
fornia (described in the Covered Services section nurse, but is only available for brief periods of cri-
of this EOC). sis and only as necessary to maintain the termi-
Behavioral Health Treatment — professional nally ill patient at home.
services and treatment programs, including ap- Copayment — the specific dollar amount that a
plied behavior analysis and evidence-based inter- Member is required to pay for Covered Services
vention programs, which develop or restore,to the after meeting any applicable Deductible.
maximum extent practicable,the functioning of an Cosmetic Surgery—surgery that is performed to
individual with pervasive developmental disorder alter or reshape normal structures of the body to
or autism. improve appearance.
Benefits (Covered Services) — those Medically Covered Services (Benefits) — those Medically
Necessary services and supplies which a Member Necessary services and supplies which a Member
is entitled to receive pursuant to the Group Health is entitled to receive pursuant to the terms of the
Service Contract. Group Health Service Contract.
BlueCard Service Area — the United States, Creditable Coverage—
Commonwealth of Puerto Rico, and U.S. Virgin
Islands. I) Any individual or group policy, Contract or
Blue Shield of California—a California not-for- program, that is written or administered by a
profit corporation, licensed as a health care service disability insurer, health care service plan, fra-
plan, and referred to throughout this EOC, as Blue ternal benefits society, self-insured employer
Shield. plan, or any other entity, in this state or else-
where, and that arranges or provides medical,
Calendar Year— the 12-month consecutive pe- hospital, and surgical coverage not designed to
riod beginning on January 1 and ending on Decem- supplement other private or governmental
ber 31 of the same calendar year. plans. The term includes continuation or con-
Care Coordination — Organized, information- version coverage,but does not include accident
driven patient care activities intended to facilitate only, credit, coverage for onsite medical clin-
the appropriate responses to a Member's health- ics, disability income, Medicare supplement,
care needs across the continuum of care. long-term care insurance, dental, vision, cov-
erage issued as a Supplement to liability insur-
Care Coordinator — An individual within a ance, insurance arising out of a workers' com-
provider organization who facilitates Care Coordi- pensation or similar law, automobile medical
nation for patients. payment insurance, or insurance under which
Care Coordinator Fee—A fixed amount paid by benefits are payable with or without regard to
a Blue Cross and/or Blue Shield Licensee to fault and that is statutorily required to be con-
providers periodically for Care Coordination under tained in any liability insurance policy or
a Value-Based Program. equivalent self-insurance.
Close Relative — the spouse, Domestic Partner, 2) The Medicare Program pursuant to Title XVIII
children, brothers, sisters, or parents of a Member. of the Social Security Act.
Coinsurance — the percentage amount that a 3) The Medicaid Program pursuant to Title XIX
Member is required to pay for Covered Services of the Social Security Act(referred to as Medi-
after meeting any applicable Deductible. Cal in California).
Continuous Nursing Services — Nursing care 4) Any other publicly sponsored program of med-
provided on a continuous hourly basis, rather than ical, hospital or surgical care, provided in this
intermittent home visits for Insureds enrolled in a state or elsewhere.
61
5) The Civilian Health and Medical Program of Dependent—the spouse or Domestic Partner, or
the Uniformed Services (CHAMPUS) pur- child, of an eligible Employee, who is determined
suant to 10 U.S.C. Chapter 55, Section 1071, to be eligible.
et seq.
1) A Dependent spouse is an individual who is
6) A medical care program of the Indian Health legally married to the Subscriber, and who is
Service or of a tribal organization. not legally separated from the Subscriber.
7) A state health benefits high risk pool. 2) A Dependent Domestic Partner is an individ-
8) The Federal Employees Health Benefits Pro- ual who meets the definition of Domestic Part-
gram, which is a health plan offered under 5 ner as defined in this Agreement.
U.S.C. Chapter 89, Section 8901 et seq. 3) A Dependent child is a child of, adopted by, or
9) A public health plan as defined by the Health in legal guardianship of the Subscriber,spouse,
Insurance Portability and Accountability Act or Domestic Partner,and who is not covered as
of 1996 pursuant to Section 2701(c)(1)(I) of a Subscriber. A child includes any stepchild,
the Public Health Service Act,and amended by child placed for adoption,or any other child for
Public Law 104-191. whom the Subscriber, spouse, or Domestic
Partner has been appointed as a non-temporary
10)A health benefit plan under Section 5(e) of the legal guardian by a court of appropriate legal
Peace Corps Act, pursuant to 22 U.S.C. jurisdiction. A child is an individual less than
2504(e). 26 years of age. A child does not include any
11)Any other creditable coverage as defined by children of a Dependent child (i.e., grandchil-
subsection (c) of Section 2704 of Title XXVII dren of the Subscriber, spouse, or Domestic
of the federal Public Health Service Act (42 Partner), unless the Subscriber, spouse, or Do-
U.S.C. Sec 300gg-3(c)). mestic Partner has adopted or is the legal
Custodial Care or Maintenance Care — care guardian of the grandchild.
furnished in the home primarily for supervisory 4) If coverage for a Dependent child would be ter-
care or supportive services, or in a facility primar- minated because of the attainment of age 26,
ily to provide room and board (which may or may and the Dependent child is disabled and inca-
not include nursing care, training in personal hy- pable of self-sustaining employment, Benefits
giene and other forms of self-care and/or supervi- for such Dependent child will be continued
sory care by a Doctor of Medicine) or care fur- upon the following conditions:
nished to a person who is mentally or physically a. the child must be chiefly dependent upon
disabled, and the Subscriber, spouse, or Domestic Part-
1) who is not under specific medical, surgical, or ner for support and maintenance;
psychiatric treatment to reduce the disability to b. the Subscriber, spouse, or Domestic Part-
the extent necessary to enable the individual to ner must submit to Blue Shield a Physi-
live outside an institution providing such care; cian's written certification of disability
or within 60 days from the date of the Em-
2) when, despite such treatment there is no rea- ployer's or Blue Shield's request; and
sonable likelihood that the disability will be so c. thereafter, certification of continuing dis-
reduced. ability and dependency from a Physician
Deductible — the Calendar Year amount which must be submitted to Blue Shield on the
the Member must pay for specific Covered Ser- following schedule:
vices before Blue Shield pays for Covered Ser- i. within 24 months after the month when
vices pursuant to the Group Health Service Con- the Dependent child's coverage would
tract. otherwise have been terminated; and
62
ii. annually thereafter on the same month a hospital, including ancillary services rou-
when certification was made in accor- tinely available to the emergency department
dance with item (1) above. In no event to evaluate the Emergency Medical Condition,
will coverage be continued beyond the and
date when the Dependent child be- 2) Such further medical examination and treat-
comes ineligible for coverage for any ment,to the extent they are within the capabili-
reason other than attained age. ties of the staff and facilities available at the
Doctor of Medicine—a licensed Medical Doctor hospital,to stabilize the Member.
(M.D.) or Doctor of Osteopathic Medicine (D.O.). 'Stabilize' means to provide medical treatment of
Domestic Partner—an individual who is person- the condition as may be necessary to assure, with
ally related to the Subscriber by a domestic part- reasonable medical probability, that no material
nership that meets the following requirements: deterioration of the condition is likely to result
1) Both partners are (a) 18 years of age or older from or occur during the transfer of the individual
and (b) of the same or different sex; from a facility, or, with respect to a pregnant
woman who is having contractions, when there is
2) The partners share (a)an intimate and commit- inadequate time to safely transfer her to another
ted relationship of mutual caring and (b) the hospital before delivery (or the transfer may pose
same common residence; a threat to the health or safety of the woman or un-
3) The partners are (a) not currently married, and born child), "Stabilize" means to deliver (includ-
(b) not so closely related by blood that legal ing the placenta).
marriage or registered domestic partnership "Post-Stabilization Care"means Medically Neces-
would otherwise be prohibited; sary services received after the treating physician
4) Both partners were mentally competent to con- determines the Emergency Medical Condition is
sent to a contract when their domestic partner- stabilized.
ship began. Emergency Services will be reviewed retrospec-
The domestic partnership is deemed created on the tively by Blue Shield to determine whether the ser-
date when both partners meet the above require- vices were for an Emergency Medical Condition.
ments. If the Member reasonably should have known that
an Emergency Medical Condition did not exist,the
Emergency Medical Condition (including a services will be covered at the applicable Partici-
psychiatric emergency) — a medical condition pating or Non-Participating Provider level of Ben-
manifesting itself by acute symptoms of sufficient efits.
severity (including severe pain) such that the ab-
sence of immediate medical attention could rea- Employee—an individual who meets the eligibil-
sonably be expected to result in any of the follow- ity requirements set forth in the Group Health Ser-
ing: vice Contract between Blue Shield and the Em-
1) placing the Member's health in serious jeop-
ployer.
ardy; Employer(Contractholder)—any person, firm,
proprietary or non-profit corporation, partnership,
2) serious impairment to bodily functions; public agency, or association that has at least 101
3) serious dysfunction of any bodily organ or employees and that is actively engaged in business
part. or service, in which a bona fide employer-em-
ployee relationship exists, in which the majority of
Emergency Services — the following services employees were employed within this state, and
provided for an Emergency Medical Condition: which was not formed primarily for purposes of
1) A medical screening examination that is within buying health care coverage or insurance.
the capability of the emergency department of
63
Experimental or Investigational in Nature — anesthetist(CRNA); clinical nurse specialist; opti-
any treatment,therapy,procedure,drug or drug us- cian; audiologist; hearing aid supplier; licensed
age, facility or facility usage, equipment or equip- clinical social worker; psychologist; marriage and
ment usage, device or device usage, or supplies family therapist; board certified behavior analyst
which are not recognized in accordance with gen- (BCBA), licensed professional clinical counselor
erally accepted professional medical standards as (LPCC); massage therapist.
being safe and effective for use in the treatment of Hemophilia Infusion Provider—a provider that
the illness, injury, or condition at issue. Services furnishes blood factor replacement products and
which require approval by the Federal government services for in-home treatment of blood disorders
or any agency thereof, or by any State government such as hemophilia.
agency, prior to use and where such approval has
not been granted at the time the services or sup- Note: A Participating home infusion agency may
plies were rendered, shall be considered experi- not be a Participating Hemophilia Infusion
mental or investigational in nature. Services or Provider if it does not have an agreement with Blue
supplies which themselves are not approved or rec- Shield to furnish blood factor replacement prod-
ognized in accordance with accepted professional ucts and services.
medical standards, but nevertheless are authorized Home Health Aide—an individual who has suc-
by law or by a government agency for use in test- cessfully completed a state-approved training pro-
ing,trials,or other studies on human patients,shall gram, is employed by a home health agency or
be considered experimental or investigational in Hospice program, and provides personal care ser-
nature. vices in the patient's home.
Family—the Subscriber and all enrolled Depen- Hospice or Hospice Agency — an entity which
dents. provides hospice services to persons with a Termi-
Group Health Service Contract (Contract) — nal Disease or Illness and holds a license as a hos-
the contract for health coverage between Blue pice pursuant to California Health and Safety Code
Shield and the Employer(Contractholder) that es- Section 1747, or a home health agency licensed
tablishes the Benefits that Subscribers and Depen- pursuant to California Health and Safety Code
dents are entitled to receive. Sections 1726 and 1747.1 which has Medicare cer-
Habilitative Services—Health care services and tification.
devices that help a person keep, learn, or improve Hospital—an entity which is:
skills and functioning for daily living. Examples 1) a licensed institution primarily engaged in pro-
include therapy for a child who is not walking or viding medical, diagnostic and surgical facili-
talking at the expected age.These services may in- ties for the care and treatment of sick and in-
clude physical and occupational therapy, speech- jured persons on an inpatient basis, under the
language pathology, and other services for people supervision of an organized medical staff, and
with disabilities in a variety of inpatient or outpa- which provides 24-hour a day nursing service
tient settings, or both. by registered nurses;
Health Care Provider — An appropriately li- 2) a psychiatric hospital accredited by the Joint
censed or certified independent practitioner in- Commission on Accreditation of Healthcare
cluding: licensed vocational nurse; registered Organizations; or
nurse; nurse practitioner; physician assistant; psy-
chiatric/mental health registered nurse; registered 3) a psychiatric health care facility as defined in
dietician; certified nurse midwife; licensed mid- Section 1250.2 of the California Health and
wife; occupational therapist; acupuncturist; regis- Safety Code.
tered respiratory therapist; speech therapist or A facility which is principally a rest home,nursing
pathologist; physical therapist; pharmacist; natur- home, or home for the aged, is not included in this
opath; podiatrist; chiropractor; optometrist; nurse definition.
64
Host Blue — The local Blue Cross and/or Blue c. not furnished primarily for the convenience
Shield Licensee in a geographic area outside of of the patient, the attending Physician or
California, within the BlueCard Service Area. other provider;
Infertility— d. furnished at the most appropriate level
1) a demonstrated condition recognized by a li- which can be provided safely and effec-
censed physician and surgeon as a cause for in- tively to the patient; and
fertility; or e) not more costly than an alternative service
2) the inability to conceive a pregnancy or to or sequence of services at least as likely to
carry a pregnancy to a live birth after a year of produce equivalent therapeutic or diag-
regular sexual relations without contraception. nostic results as to the diagnosis or treat-
ment of the Member's illness, injury, or
Intensive Outpatient Program — an outpatient disease.
mental health or substance use disorder treatment
program utilized when a patient's condition re- 2) Hospital inpatient services which are Medi-
quires structure, monitoring, and medical/psycho- cally Necessary include only those services
logical intervention at least three hours per day, which satisfy the above requirements, require
three times per week. the acute bed-patient (overnight) setting, and
which could not have been provided in the
Inter-Plan Arrangements — Blue Shield's rela-
tionships with other Blue Cross and/or Blue Shield Physicians office, the Outpatient Department
th-
Licensees,governed by the Blue Cross Blue Shield of a Hospital, affecting or in another lesser facility condition
out adversely acting the patient's condition
Association. or the quality of medical care rendered. Inpa-
Late Enrollee—an eligible Employee or Depen- tient services that are not Medically Necessary
dent who declined enrollment in this coverage at include hospitalization:
the time of the initial enrollment period, and who a. for diagnostic studies that could have been
subsequently requests enrollment for coverage , provided on an outpatient basis;
provided that the initial enrollment period was a
period of at least 30 days. Coverage is effective for b. for medical observation or evaluation;
a Late Enrollee the earlier of 12 months from the c. for personal comfort;
date a written request for coverage is made or at
the Employer's next Open Enrollment Period. An d. in a pain management center to treat or
eligible Employee or Dependent may qualify for a cure chronic pain; and
Special Enrollment Period. e. for inpatient Rehabilitative Services that
Medical Necessity (Medically Necessary)— can be provided on an outpatient basis.
Benefits are provided only for services that are 3) Blue Shield reserves the right to review all
Medically Necessary. claims to determine whether services are Med-
ically Necessary, and may use the services of
I) Services that are Medically Necessary include Physician consultants,peer review committees
only those which have been established as safe of professional societies or Hospitals, and
and effective,are furnished under generally ac- other consultants.
cepted professional standards to treat illness,
injury or medical condition, and which, as de- Member—an individual who is enrolled and
termined by Blue Shield, are: maintains coverage in the Group Health Service
a. consistent with Blue Shield medical pol-
Contract as either a Subscriber or a Dependent.
icy; Mental Health Condition — mental disorders
listed in the most current edition of the Diagnostic
b. consistent with the symptoms or diagnosis; & Statistical Manual of Mental Disorders (DSM),
65
including Severe Mental Illnesses and Serious Office Visits for Outpatient Mental Health and
Emotional Disturbances of a Child. Substance Use Disorder Services—professional
Mental Health Service Administrator (MHSA) office visits for the diagnosis and treatment of
—The MHSA is a specialized health care service Mental Health and Substance Use Disorder
plan licensed by the California Department of Conditions, including the individual, family or
Managed Health Care. Blue Shield contracts with group setting.
the MHSA to underwrite and deliver Blue Shield's Open Enrollment Period — that period of time
Mental Health and Substance Use Disorder Ser- set forth in the Contract during which eligible Em-
vices through a separate network of MHSA Partic- ployees and their Dependents may enroll in this
ipating Providers. coverage, or transfer from another health benefit
Mental Health Services — services provided to plan sponsored by the Employer to this coverage.
treat a Mental Health Condition. Orthosis (Orthotics) — an orthopedic appliance
MHSA Non-Participating Provider — a or apparatus used to support, align,prevent or cor-
provider who does not have an agreement in effect rect deformities, or to improve the function of
with the MHSA for the provision of Mental Health movable body parts.
or Substance Use Disorder Services. Other Outpatient Mental Health and Substance
MHSA Participating Provider—a provider who Use Disorder Services—Outpatient Facility and
has an agreement in effect with the MHSA for the professional services for the diagnosis and treat-
provision of Mental Health Services or Substance ment of Mental Health Conditions and Substance
Use Disorder Services. Use Disorder Conditions, including, but not lim-
ited to the following:
Negotiated Arrangement (Negotiated National
Account Arrangement)—An agreement negoti- I) Partial Hospitalization
ated between a Control/Home Licensee and one or 2) Intensive Outpatient Program
more Par/Host Licensees for any National Account 3) Electroconvulsive Therapy
that is not delivered through the BlueCard Pro-
gram. 4) Office-Based Opioid Treatment
Non-Participating (Non-Participating 5) Transcranial Magnetic Stimulation
Provider) — refers to any provider who has not 6) Behavioral Health Treatment
contracted with Blue Shield to accept Blue
Shield's payment, plus any applicable Member 7) Psychological Testing
Deductible, Copayment, Coinsurance, or amounts These services may also be provided in the office,
in excess of specified Benefit maximums, as pay- home or other non-institutional setting.
ment in full for Covered Services provided to
Members. Out-of-Area Covered Health Care Services —
Medically Necessary Emergency Services, Urgent
This definition does not apply to providers of Men- Services,or Out-of-Area Follow-up Care provided
tal Health and Substance Use Disorder Services, outside the Plan Service Area.
which is defined separately under the MHSA Non-
Participating Provider definition. Out-of-Area Follow-up Care — non-emergent
Medically Necessary services to evaluate the
Occupational Therapy—treatment under the di- Member's progress after Emergency or Urgent
rection of a Doctor of Medicine and provided by a Services provided outside the service area.
certified occupational therapist, or other appropri-
ately licensed Health Care Provider, utilizing arts, Out-of-Pocket Maximum — the highest De-
crafts, or specific training in daily living skills, to ductible, Copayment and Coinsurance amount an
improve and maintain a patient's ability to func- individual or Family is required to pay for desig-
tion. nated Covered Services each year as indicated in
the Summary of Benefits. Charges for services that
66
are not covered, charges in excess of the Allow- even if the Member lives longer than one year. A
able Amount or contracted rate, do not accrue to Period of Care begins the first day the Member re-
the Calendar Year Out-of-Pocket Maximum. ceives Hospice services and ends when the certi-
Outpatient Department of a Hospital—any de- fied timeframe has elapsed.
partment or facility integrated with the Hospital Physical Therapy—treatment provided by a reg-
that provides outpatient services under the Hospi- istered physical therapist, certified occupational
tal's license, which may or may not be physically therapist or other appropriately licensed Health
separate from the Hospital. Care Provider. Treatment utilizes physical agents
Outpatient Facility — a licensed facility which and therapeutic procedures, such as ultrasound,
provides medical and/or surgical services on an heat, range of motion testing, and massage, to im-
outpatient basis. The term does not include a prove a patient's musculoskeletal, neuromuscular
Physician's office or a Hospital. and respiratory systems.
Partial Hospitalization Program (Day Treat- Physician—a licensed Doctor of Medicine, clin-
ment) — an outpatient treatment program that ical psychologist, research psychoanalyst, dentist,
may be free-standing or Hospital-based and pro- licensed clinical social worker, optometrist, chiro-
practor,vides services at least five hours per day,four days podiatrist, audiologist, registered physical
per week. Patients may be admitted directly to this therapist, or licensed marriage and family thera-
level of care,or transferred from inpatient care fol- pest.
lowing stabilization. Plan—the Blue Shield PPO Plan.
Participating Hospice or Participating Hospice Premium (Dues) — the monthly prepayment
Agency —an entity which: (1) provides Hospice made to Blue Shield on behalf of each Member by
services to Terminally III Members and holds a li- the Contractholder for coverage under the Group
cense, currently in effect, as a Hospice pursuant to Health Service Contract.
Health and Safety Code Section 1747, or a home Preventive Health Services — mean those pri-
health agency licensed pursuant to Health and mary preventive medical Covered Services, in-
Safety Code Sections 1726 and 1747.1 which has cluding related laboratory services,for early detec-
Medicare certification; and (2) has either con- tion of disease as specifically described in the Pre-
tracted with Blue Shield of California or has re- ventive Health Benefits section of this EOC.
ceived prior approval from Blue Shield of Califor-
nia to provide Hospice service Benefits pursuant to Prosthesis(es) (Prosthetics) — an artificial part,
the California Health and Safety Code Section appliance or device used to replace a missing part
1368.2. of the body.
Participating (Participating Provider) —refers Provider Incentive — An additional amount of
to a provider who has contracted with Blue Shield compensation paid to a healthcare provider by a
to accept Blue Shield's payment,plus any applica- Blue Cross and/or Blue Shield Plan, based on the
ble Member Deductible, Copayment, Coinsur- provider's compliance with agreed-upon proce-
ance, or amounts in excess of specified Benefit dural and/or outcome measures for a particular
maximums, as payment in full for Covered Ser- group of covered persons.
vices provided to Members of this Plan. Psychological Testing — testing to diagnose a
This definition does not apply to providers of Men- Mental Health Condition when referred by an
tal Health Services and Substance Use Disorder MHSA Participating Provider.
Services, which is defined separately under the Reasonable and Customary Charge
-
MHSA Participating Provider definition.
1) In California: The lower of: (a) the provider's
Period of Care—the timeframe the Participating billed charge, or(b)the amount determined by
Provider certifies or recertifies that the Member Blue Shield to be the reasonable and custom-
requires and remains eligible for Hospice care,
67
ary value for the services rendered by a Non- for the child's age according to expected de-
Participating Provider based on statistical in- velopmental norms; and
formation that is updated at least annually and 2) meet the criteria in paragraph (2) of subdivi-
considers many factors including, but not lim- sion (a) of Section 5600.3 of the Welfare and
ited to, the provider's training and experience, Institutions Code. This section states that
and the geographic area where the services are Members of this population shall meet one or
rendered. more of the following criteria:
2) Outside of California: The lower of. (a) the a. As a result of the mental disorder the child
provider's billed charge, or (b) the amount, if has substantial impairment in at least two
any, established by the laws of the state to be
paid for Emergency Services. of the following areas: self-care, school
functioning,family relationships,or ability
Reconstructive Surgery — surgery to correct or to function in the community: and either of
repair abnormal structures of the body caused by the following has occurred: the child is at
congenital defects, developmental abnormalities, risk of removal from home or has already
trauma, infection,tumors,or disease to do either of been removed from the home or the mental
the following: (1) to improve function; or (2) to disorder and impairments have been
create a normal appearance to the extent possible; present for more than 6 months or are
dental and orthodontic services that are an integral likely, to continue for more than one year
part of surgery for cleft palate procedures. without treatment;
Rehabilitative Services—inpatient or outpatient b. The child displays one of the following:
care furnished to an individual disabled by injury psychotic features,risk of suicide or risk of
or illness, including Severe Mental Illnesses and violence due to a mental disorder.
Severe Emotional Disturbances of a Child, in or- Severe Mental Illnesses — conditions with the
der to restore an individual's ability to function to following diagnoses: schizophrenia, schizo affec-
the maximum extent practical. Rehabilitative Ser- tive disorder, bipolar disorder (manic depressive
vices may consist of Physical Therapy, Occupa- illness), major depressive disorders, panic disor-
tional Therapy, and/or Respiratory Therapy. der, obsessive-compulsive disorder, pervasive de-
Residential Care— Mental Health or Substance velopmental disorder or autism, anorexia nervosa,
Use Disorder Services provided in a facility or a bulimia nervosa.
free-standing residential treatment center that pro- Skilled Nursing — services performed by a li-
vides overnight/extended-stay services for Mem- censed nurse (either a registered nurse or a li-
bers who do not require acute inpatient care. censed vocational nurse).
Respiratory Therapy—treatment, under the di- Skilled Nursing Facility—a facility with a valid
rection of a Doctor of Medicine and provided by a license issued by the California Department of
certified respiratory therapist, or other appropri- Public Health as a Skilled Nursing Facility or any
ately licensed or certified Health Care Provider to similar institution licensed under the laws of any
preserve or improve a patient's pulmonary func-
tion. other state, territory, or foreign country. Also in-
cluded is a Skilled Nursing unit within a Hospital.
Serious Emotional Disturbances of a Child — Special Enrollment Period — a period during
refers to individuals who are minors under the age which an individual who experiences certain quali-
of 18 years who:
Eying events may enroll in, or change enrollment
1) have one or more mental disorders in the most in,this Health Plan outside of the initial and annual
recent edition of the Diagnostic and Statistical Open Enrollment Periods. An eligible Employee
manual of Mental Disorders (other than a pri- or an Employee's Dependent has a 30-day Special
mary substance use disorder or developmental Enrollment Period, except as otherwise stated, if
disorder),that results in behavior inappropriate any of the following occurs:
68
1) The eligible Employee or Dependent meets all the employer, as described in Section 3751.5
of the following requirements: and 3766 of the Family Code; or
a. The Employee or Dependent was covered 3) For eligible Employees or Dependents who fail
under another employer health benefit plan to elect coverage in this Plan during their ini-
or had other health insurance coverage at tial enrollment period, the Plan cannot produce
the time he was offered enrollment under a written statement from the Employer stating
this Plan; that prior to declining coverage,he or the indi-
b. The Employee or Dependent certified, at vidual through whom he was covered as a De-
the time of the initial enrollment, that cov- pendent, was provided with and signed ac-
erage under another employer health bene- knowledgment of a Refusal of Personal Cover-
fit plan or other health insurance was the age specifying that failure to elect coverage
reason for declining enrollment provided during the initial enrollment period permits the
that, if he was covered under another em- Plan to impose, at the time of his later decision
ployer health plan or had other health in- to elect coverage, an exclusion from coverage
surance coverage, he was given the oppor- for a period of up to 12 months, unless he or
tunity to make the certification required she meets the criteria specified in paragraphs 1
and was notified that failure to do so could or 2 above; or
result in later treatment as a Late Enrollee; 4) For eligible Employees or Dependents who
c. The Employee or Dependent has lost or were eligible for coverage under the Healthy
will lose coverage under another employer Families Program or Medi-Cal whose cover-
health benefit plan as a result of termina- age is terminated as a result of the loss of such
tion of his employment; or of an individual eligibility, provided that enrollment is re-
through whom he was covered as a Depen- quested no later than 60 days after the termina-
dent,change in his employment status or of tion of coverage; or
an individual through whom he was cov- 5) For Employees or Dependents who are eligible
ered as a Dependent, termination of the for the Healthy Families Program or the Medi-
other plan's coverage, exhaustion of CO- Cal premium assistance program and who re-
BRA continuation coverage, cessation of quest enrollment within 60 days of the notice
an employer's contribution toward his cov- of eligibility for these premium assistance pro-
erage, death of an individual through grams; or
whom he was covered as a Dependent, or 6) For eligible Employees who decline coverage
legal separation, divorce or termination of during the initial enrollment period and subse-
a domestic partnership; and quently acquire Dependents through marriage,
d. The Employee or Dependent requests en- establishment of domestic partnership,birth,or
rollment within 30 days after termination placement for adoption, and who enroll for
of coverage or employer contribution to- coverage for themselves and their Dependents
ward coverage provided under another em- within 30 days from the date of marriage, es-
ployer health benefit plan; or tablishment of domestic partnership, birth, or
2) A court has ordered that coverage be provided placement for adoption.
for a spouse or Domestic Partner or minor Special Food Products — a food product which
child under a covered Employee's health ben- is both of the following:
efit Plan.The health Plan shall enroll a Depen- 1) Prescribed by a physician or nurse practitioner
dent child effective the first day of the month for the treatment of phenylketonuria (PKU)
following presentation of a court order by the and is consistent with the recommendations
district attorney, or upon presentation of a and best practices of qualified health profes-
court order or request by a custodial party or
sionals with expertise germane to, and experi-
69
ence in the treatment and care of, phenylke- nally Ill) — a medical condition resulting in a life
tonuria (PKU). It does not include a food that expectancy of one year or less, if the disease fol-
is naturally low in protein, but may include a lows its natural course.
food product that is specially formulated to Total Disability (or Totally Disabled)have less than one gram of protein per serving;
2) Used in place of normal food products, such as 1) in the case of an Employee, or Member other-
grocery store foods, used by the general popu- wise eligible for coverage as an Employee, a
disability which prevents the individual from
lation. working with reasonable continuity in the in-
Speech Therapy—treatment, under the direction dividual's customary employment or in any
of a Doctor of Medicine and provided by a licensed other employment in which the individual rea-
speech pathologist, speech therapist, or other ap- sonably might be expected to engage, in view
propriately licensed or certified Health Care of the individual's station in life and physical
Provider to improve or retrain a patient's vocal or and mental capacity;
swallowing skills which have been impaired by di- 2) in the case of a Dependent, a disability which
agnosed illness or injury. prevents the individual from engaging with
Subacute Care— Skilled Nursing or skilled Re- normal or reasonable continuity in the indi-
habilitative Services provided in a Hospital or vidual's customary activities or in those in
Skilled Nursing Facility to patients who require which the individual otherwise reasonably
skilled care such as nursing services, physical, oc- might be expected to engage, in view of the
cupational or speech therapy, a coordinated pro- individual's station in life and physical and
gram of multiple therapies or who have medical mental capacity.
needs that require daily Registered Nurse monitor- Urgent Services — those Covered Services ren-
ing.A facility which is primarily a rest home, con- dered outside of the Plan Service Area (other than
valescent facility or home for the aged is not in- Emergency Services) which are Medically Neces-
cluded. sary to prevent serious deterioration of Member's
Subscriber — an eligible Employee who is en- health resulting from unforeseen illness, injury, or
rolled and maintains coverage under the Group complications of an existing medical condition,for
Health Service Contract. which treatment cannot reasonably be delayed un-
Substance Use Disorder Condition—drug or til the Member returns to the Plan Service Area.
alcohol abuse or dependence.
Value-Based Program (VBP) — An outcomes-
Substance Use Disorder Services — services based payment arrangement and/or a coordinated
provided to treat a Substance Use Disorder Condi- care model facilitated with one or more local
tion. providers that is evaluated against cost and qual-
Terminal Disease or Terminal Illness (Termi- ity metrics/factors and is reflected in provider pay-
ment.
70
Outpatient Prescription Drug Rider Group Rider
PPO
Enhanced Rx $10/15/30 with $250 Pharmacy Deductible
Summary of Benefits
This Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.
Pharmacy Network: Rx Ultra
Drug Formulary: Plus Formulary
Calendar Year Pharmacy Deductible (CYPD)'
A Calendar Year Pharmacy Deductible (CYPD) is the amount a Member pays each Calendar Year before Blue Shield
pays for covered Drugs under the outpatient prescription Drug Benefit.Blue Shield pays for some prescription Drugs be-
fore the Calendar Year Pharmacy Deductible is met, as noted in the Prescription Drug Benefits chart below.
When using a Participatingz or
Non-Participating3 Pharmacy
Calendar Year Pharmacy Deductible Per Member $250
Prescription Drug Benefits^•s Your pa ment
When using a When using a
Participating CYPDr Non-Participating CYPDr
Pharmac s a lies Pharmacy3 applies
Retail pharmacy prescription Drugs
Per prescription, up to a 30-day supply. o
Applicable Tier 1, 0
Contraceptive Drugs and devices $0 Tier 2,or Tier 3 Co- o
payment
Tier 1 Drugs $10/prescription 25%plus 0
$10/prescription L
Tier 2 Drugs $15/prescription v 25%plus v j
$15/prescription m
Tier 3 Drugs $30/prescription v 25%plus
$30/prescription 0
30%up to
Tier 4 Drugs (excluding Specialty Drugs) 30%up to $200/prescription 9
$200/prescription plus 25%of pur- ro
chase price
`c
Mail service pharmacy prescription Drugs 'aa
Per prescription, up to a 90-day supply. o.
Contraceptive Drugs and devices $0 Not covered 'a
Tier 1 Drugs $20/prescription Not covered c
Tier 2 Drugs $30/prescription Not covered
0
Tier 3 Drugs $60/prescription Not covered 'c
30%up to 0Not covered
Ter 4 Drugs (excluding Specialty Drugs) $400/prescription j
0
Network Specially Pharmacy Drugs -a
m
Per prescription, up to a 30-day supply. h
Tier 4 Specialty Drugs 30%up to „ Not covered
$200/prescription m
71
Oral anticancer Drugs 30%up to Not covered
$200/prescription
Per prescription, up to a 30-day supply.
Notes
1 Calendar Year Pharmacy Deductible(CYPD):
Calendar Year Pharmacy Deductible explained.A Calendar Year Pharmacy Deductible is the amount you pay each
Calendar Year before Blue Shield pays for outpatient prescription Drugs under this Benefit.
If this Benefit has a Calendar Year Pharmacy Deductible, outpatient prescription Drugs subject to the Deductible are
identified with a check mark (v) in the Benefits chart above.
Outpatient prescription Druas not subject to the Calendar Year Pharmacy Deductible. Some outpatient prescription
Drugs received from Participating Pharmacies are paid by Blue Shield before you meet any Calendar Year Pharmacy
Deductible.These outpatient prescription Drugs do not have a check mark (v) next to them in the "CYPD applies"
column in the Prescription Drug Benefits chart above.
2 Using Participating Pharmacies:
Participating Pharmacies have a contract to provide outpatient prescription Drugs to Members. When you obtain
covered prescription Drugs from a Participating Pharmacy,you are only responsible for the Copayment or Coinsur-
ance, once any Calendar Year Pharmacy Deductible has been met.
Participating Pharmacies and Druo Formulary. You can find a Participating Pharmacy and the Drug Formulary by vis-
iting www.blueshieldca.com/wellness/drugs/formulary#heading2.
3 Using Non-Participating Pharmacies:
Non-Participating Pharmacies do not have a contract to provide outpatient prescription Drugs to Members. When
you obtain prescription Drugs from a Non-Participating Pharmacy,you must pay all charges for the prescription,then
submit a completed claim form for reimbursement.You will be reimbursed based on the price you paid for the Drug.
4 Outpatient Prescription Drug Coverage:
Medicare Part D-creditable coverage-
This prescription Drug coverage is on average equivalent to or better than the standard benefit set by the federal gov-
ernment for Medicare Part D(also called creditable coverage).Because this prescription Drug coverage is creditable,
you do not have to enroll in Medicare Part D while you maintain this coverage;however,you should be aware that if
you do not enroll in Medicare Part D within 63 days following termination of this coverage, you could be subject to
Medicare Part D premium penalties.
5 Outpatient Prescription Drug Coverage:
Brand Drug coverage when a Generic Drug is available. If you select a Brand Drug when a Generic Drug equivalent
is available,you are responsible for the difference between the cost to Blue Shield for the Brand Drug and its Generic
Drug equivalent plus the Tier 1 Copayment or Coinsurance.This difference in cost will not count towards any Calen-
dar Year Pharmacy Deductible,medical Deductible,or the Calendar Year Out-of-Pocket Maximum. If your Physician
or Health Care Provider prescribes a Brand Drug and indicates that a Generic Drug equivalent should not be substi-
tuted, you pay your applicable tier Copayment or Coinsurance. If your Physician or Health Care Provider does not
indicate that a Generic Drug equivalent should not be substituted, you may request a Medical Necessity Review. If
approved,the Brand Drug will be covered at the applicable Drug tier Copayment or Coinsurance.
Short-Cycle Specialty Drug program.This program allows initial prescriptions for select Specialty Drugs to be filled for a
15-day supply with your approval.When this occurs,the Copayment or Coinsurance will be pro-rated.
Benefit designs may be modified to ensure compliance with State and Federal requirements.
72
Outpatient Prescription Drug Benefit 2• Recommended by the P&T Committee
based on drug safety,efficacy and cost or;
Your plan provides coverage for Outpatient Prescription 3. Generally, have a preferred and often less
Drugs as described in this Supplement. This Prescription costly therapeutic alternative at a lower tier.
Drug Benefit is separate from the medical Plan coverage. 1. Food and Drug Administration (FDA) or
The Medical Plan Deductible and the Coordination ofBene- Tier 4 drug manufacturer limits distribution to spe-
fits provisions do not apply to this Outpatient Prescription cialty pharmacies or;
Drug Supplement. However, the Calendar Year Out-of- 2. Self administration requires training,clinical
Pocket Maximum, general provisions and exclusions of the monitoring or;
Group Health Service Contract apply. 3. Drug was manufactured using biotechnol-
ogy or;
A Physician or Health Care Provider must prescribe all 4. Plan cost net of rebates is>$600
Drugs covered under this Benefit,including over-the-counter
items.You must obtain all Drugs from a Participating Phar- You can find the Drug Formulary at
macy,except as noted below. https://www.blueshieldca.com/bsea/phannacy/home.sp.
Ad- You can also contact Customer Service at the number pro-
Blue Shield's Drug Formulary is a list of Food and Drug; vided on the back page of your EOC to ask if a specific Drug
ministration (FDA)-approved preferred Generic and Brand is included in the Formulary,or to request a printed copy.
Drugs that assists Physicians and Health Care Providers to
prescribe Medically Necessary and cost-effective Drugs. Obtaining Outpatient Prescription Drugs
Some Drugs, most Specialty Drugs, and prescriptions for at a Participating Pharmacy
Drugs exceeding specific quantity limits require prior autho- You must present a Blue Shield Identification Card at a Par-
rization by Blue Shield for Medical Necessity,as described ticipating Pharmacy to obtain Drugs under the Outpatient
in the Prior A uthorization/Exception Request Process/Step prescription Drug benefit.You can obtain prescription Drugs
Therapy section. You, your Physician or Health Care at any retail Participating Pharmacy unless the Drug is a Spe-
Provider may request prior authorization from Blue Shield. cialty Drug. Refer to the section Obtaining Specialty Drugs
Outpatient Drug Formulary through the Specialty Drug Program for additional informa-
tion.You can locate a retail Participating Pharmacy by visit-
Blue Shield's Drug Formulary is a list of Food and Drug Ad- ing https://www.blueshieldca.com/bsea/i)hartnacy/honie.sy
ministration (FDA)-approved preferred Generic and Brand or by calling Customer Service at the number listed on the
Drugs that assists Physicians and Health Care Providers to Identification Card.
prescribe Medically Necessary and cost-effective Drugs. Blue Shield negotiates contracted rates with Participating
Blue Shield's Formulary is established by Blue Shield's Pharmacies for covered Drugs.If your plan has a Pharmacy
Pharmacy and Therapeutics Committee. This Committee Deductible,you are responsible forpaying the full contracted
consists of physicians and pharmacists responsible for eval- rate for Drugs until you meet the Member Calendar Year
uating Drugs for relative safety,effectiveness,health benefit Pharmacy Deductible.Drugs in Tier I are not subject to,and
based on the medical evidence, and comparative cost. They will not accrue to the Calendar Year Pharmacy Deductible.
review new Drugs, dosage forms, usage and clinical data to You must pay the applicable Copayment or Coinsurance for
update the Formulary during scheduled meetings four times each prescription Drug when you obtain it from a Participat-
a year.Note:Your Physician or Health Care Provider might ing Pharmacy. When the Participating Pharmacy's con-
prescribe a Drug even though the Drug is not included on the tracted rate is less than your Copayment or Coinsurance,you
Formulary. only pay the contracted rate. This amount will apply to any
The Formulary is categorized into drug tiers as described in applicable Deductible and Out-of-Pocket Maximum. There
is no Copayment or Coinsurance for generic FDA-approved
the chart below. Your Copayment or Coinsurance will vary
based on the drug tier. contraceptive Drugs and devices obtained from a Participat-
ing Pharmacy. Brand contraceptives are covered without a
Drug Description Copayment or Coinsurance when Medically Necessary. See
Tier the Prior Authorization/Exception Request Process/Step
Tier 1 Most Generic Drugs or low cost preferred Therapy section.
Brands. If your Physician or Health Care Provider prescribes a Brand
Tier 2 1. Non-preferred Generic Drugs or; Drug and indicates that a Generic Drug equivalent should not
2. Preferred Brand Name Drags or; be substituted, you pay your applicable tier Copayment or
3. Recommended by the plan's Pharmacy and Coinsurance.
Therapeutics (P&T) Committee based on
drug safety.efficacy and cost. If you select a Brand Drug when a Generic Drug equivalent
I. Non-preferred Brand Drugs or; is available, you must pay the difference in cost, plus your
Tier 3 Tier 1 Copayment or Coinsurance.This is calculated by tak-
74
ing the difference between the Participating Pharmacy's con- Blue Shield of California
tracted rate for the Brand Drug and the Generic Drug equiv- P.O.Box 419019,
alent,plus the Generic Drug Copayment or Coinsurance.For Dept. 191
example,you select Brand Drug"A"when there is an equiv- Kansas City,MO 64141
alent Generic Drug "A" available. The Participating Phar- • You will be reimbursed as shown on the Summary of
macy's contracted rate for Brand Drug"A" is$300,and the
contracted rate for Generic Drug"A"is$100.You would be Benefits,based on the price you paid for the Drugs.
responsible for paying the$200 difference in cost,plus your If you obtain Drugs from a Non-Participating Pharmacy for
Tier 1 Copayment or Coinsurance. This difference in cost a covered emergency,Blue Shield will reimburse you based
does not apply to the Member Calendar Year Pharmacy De- on the price you paid for the Drugs, minus any applicable
ductible or the Calendar Year Out-of-Pocket Maximum. Deductible,Copayment or Coinsurance.
If your Physician or Health Care Provider does not indicate You may obtain a claim form by calling Customer Service or
that a Generic Drug equivalent should not be substituted,you by visiting www.blueshieldca.com.Claims must be received
can request an exception to paying the difference in cost be- within one year from the date of service to be considered for
tween the Brand Drug and Generic Drug equivalent through payment.Claim submission is not a guarantee of payment.
the Blue Shield prior authorization process.The request is re-
viewed for Medical Necessity. See the section on Prior Au_ Obtaining Outpatient Prescription Drugs
thorization/Exception Request Process/Step Therapy below through the Mail Service Prescription Drug
for more information on the approval process. If the request Program
is approved,you pay only the applicable tier Copayment or
Coinsurance. You have an option to use Blue Shield's Mail Service Pre-
scription Drug Program when you take maintenance Drugs
Blue Shield created a Patient Review and Coordination for an ongoing condition.This allows you to receive up to a
(PRC) program to help reduce harmful prescription drug 90-day supply of your Drug and may help you to save
misuse and the potential for abuse.Examples of harmful mis- money.You may enroll online,by phone,or by mail.Please
use include obtaining an excessive number of prescription allow up to 14 days to receive the Drug. Your Physician or
medications or obtaining very high doses of prescription opi- Health Care Provider must indicate a prescription quantity
oids from multiple providers or pharmacies within a 90-day equal to the amount to be dispensed.Specialty Drugs are not
period. If Blue Shield determines a Member is using pre- available through the Mail Service Prescription Drug Pro-
scription drugs in a potentially harmful, abusive manner, gram.
Blue Shield may,subject to certain exemptions and upon 90 You must pay the applicable Mail Service Prescription Drug
days'advance notice,restrict a Member to obtaining all non- Copayment or Coinsurance for each prescription Drug.
emergent outpatient prescriptions drugs at a single pharmacy
home.This restriction applies for a 12-month period and may Visit www.blueshieldca.com or call Customer Service to get
be renewed. The pharmacy home, a single Participating additional information about the Mail Service Prescription
Pharmacy,will be assigned by Blue Shield or a Member may Drug Program.
request to select a pharmacy home.Blue Shield may also re- Obtaining Specialty Drugs through the
quire prior authorization for all opioid medications if suffi- Specialty Drug Program
cient medical justification for their use has not been pro-
vided. Members that disagree with their enrollment in the Specialty Drugs are Drugs requiring coordination of care,
PRC program can file an appeal or submit a grievance to close monitoring, or extensive patient training for self-ad-
Blue Shield as described in the Grievance Process section. ministration that cannot be met by a retail pharmacy and are
Members selected for participation in the PRC will receive a available at a Network Specialty Pharmacy.Specialty Drugs
brochure with full program details, including participation may also require special handling or manufacturing pro-
exemptions.Any interested Member can request a PRC pro- cesses (such as biotechnology), restriction to certain Physi-
gram brochure by calling Customer Service at the number cians or pharmacies,or reporting of certain clinical events to
listed on their Identification Card. the FDA.Specialty Drugs are generally high cost.
Obtaining Outpatient Prescription Drugs Specialty Drugs are available exclusively from a Network
g p p g Specialty Pharmacy. A Network Specialty Pharmacy gro-
at a Non-Participating Pharmacy vides Specialty Drags by mail or upon your request, will
When you obtain Drugs from a Non-Participating Phar- transfer the Specialty Drug to an associated retail store for
pickup. See Obtaining Outpatient Prescription Drugs at a
macy: Non-Participating Pharmacy.
• You must first pay all charges for the prescription, A Network Specialty Pharmacy offers 24-hour clinical ser-
• Submit a completed Prescription Drug Claim form for vices,coordination of care with Physicians,and reporting of
reimbursement to: certain clinical events associated with select Drugs to the
75
FDA.To select a Network Specialty Pharmacy,you may go Step therapy is the process of beginning therapy for a medi-
to http://www.blueshieldca.com or call Customer Service. cal condition with Drugs considered first-line treatment or
Go to http://www.blueshieldea.com for a complete list of that are more cost-effective,then progressing to Drugs that
Specialty Drugs.Most Specialty Drugs require prior autho- are the next line in treatment or that may be less cost-effec-
tive. Step therapy requirements are based on how the FDA
rization for Medical Necessity by Blue Shield, as described recommends that a drug should be used, nationally recog-
in the Prior Authorization/Exception Request Process/Step nized treatment guidelines, medical studies, information
Therapy section. from the drug manufacturer, and the relative cost of treat-
Prior Authorization/Exception Request ment for a condition. If step therapy coverage requirements
Process/Step Therapy are not met for a prescription and your Physician believes the
medication is Medically Necessary, the prior authorization
Some Drugs and Drug quantities require prior approval for process may be utilized and timeframes previously described
Medical Necessity before they are eligible for coverage un- will also apply.
der the Outpatient Prescription Drug Benefit.This process is If Blue Shield denies a request for prior authorization or an
called prior authorization. exception request,you,your representative, or Health Care
The following Drugs require prior authorization: Provider can file a grievance with Blue Shield.
• Some Formulary,compound Drugs,and most Specialty See the Grievance Process portion of your EOC for informa-
Drugs require prior authorization. tion on filing a grievance,your right to seek assistance from
the Department of Managed Health Care, and your rights to
• Drugs exceeding the maximum allowable quantity independent medical review.
based on Medical Necessity and appropriateness ofther-
apy. Limitation on Quantity of Drugs that May
• Brand contraceptives may require prior authorization to Be Obtained Per Prescription or Refill
be covered without a Copayment or Coinsurance. I. Except as otherwise stated below,you may receive up to
Blue Shield covers compounded medication(s)when: a 30-day supply of Outpatient Prescription Drugs. If a
Drug is available only in supplies greater than 30 days,
• The compounded medication(s) include at least one you must pay the applicable retail Copayment or Coin-
Drug, surance for each additional 30-day supply.
• There are no FDA-approved, commercially available, 2. If you or your Health Care Provider request a partial fill
medically appropriate alternative, of a Schedule II Controlled Substance prescription,your
Copayment or Coinsurance will be pro-rated. The re-
• The compounded medication is self-administered,and maining balance of any partially filled prescription can-
• Medical literature supports its use for the diagnosis. not be dispensed more than 30 days from the date the
prescription was written.
You must pay the Tier 3 Copayment or Coinsurance for cov-
ered compound Drugs. 3. Blue Shield has a Short Cycle Specialty Drug Program.
With your agreement, designated Specialty Drugs may
You, your Physician or Health Care Provider may request be dispensed for a 15-day trial supply at a pro-rated Co-
prior authorization for the Drugs listed above by submitting payment or Coinsurance for an initial prescription.This
supporting information to Blue Shield.Once Blue Shield re- program allows you to receive a 15-day supply of your
ceives all required supporting information,we will provide Specialty Drug and determine whether you will tolerate
prior authorization approval or denial, based upon Medical it before you obtain the full30-day supply.This program
Necessity, within 72 hours in routine circumstances or 24 can help you save out of pocket expenses if you cannot
hours in exigent circumstances.Exigent circumstances exist tolerate the Specialty Drug. The Network Specialty
when a Member has a health condition that may seriously Pharmacy will contact you to discuss the advantages of
jeopardize the Member's life, health, or ability to regain the program, which you can elect at that time. You or
maximum function or when a Member is undergoing a cur- your Physician may choose a full 30-day supply for the
rent course of treatment using a Non-Formulary Drug. first fill.
To request coverage for a Non-Formulary Drug, you, your If you agree to a 15-day trial, the Network Specialty
representative, or Health Care Provider may submit an ex- Pharmacy will contact you prior to dispensing the re-
ception request to Blue Shield.Once all required supporting maining 15-day supply to confirm that you are tolerat-
information is received,Blue Shield will approve or deny the ing the Specialty Drug.You can find a list of Specialty
exception request,based upon Medical Necessity,within 72 Drugs in the Short Cycle Specialty Drug Program by
hours in routine circumstances or 24 hours in exigent circum- visiting https:/hvww.blueshieldca.com/bsca/phar-
stances. macy/home.sp or by calling Customer Service.
76
4. You may receive up to a 90-day supply of Drugs in the 7. Blood or blood products.See the Hospital Benefits sec-
Mail Service Prescription Drug Program.Note: if your tion of your EOC.
Physician or Health Care Provider writes a prescription 8 Drugs when prescribed for cosmetic purposes.This in-
for less than a 90-day supply,the mail service pharmacy cludes, but is not limited to, drugs used to slow or re-
will dispense that amount and you are responsible for verse the effects of skin aging or to treat hair loss.
the applicable Mail Service Copayment or Coinsurance.
Refill authorizations cannot be combined to reach a 90- 9. Medical food, dietary, or nutritional products. See the
day supply. Home Health Care Benefits, Home Infusion and Home
5. Select over-the-counter (OTC) drugs with a United Injectable Therapy Benefits, PKU-Related Formulas
States Preventive Services Task Force(USPSTF)rating and Special Food Product Benefits sections of your
of A or B may be covered at a quantity greater than a 30- EOC.
day supply. 10. Any Drugs which are not considered to be safe for self-
6. You may receive up to a 12-month supply of contracep- administration. These medications may be covered un-
tive Drugs. der the Home Health Care Benefits, Home Infusion and
Home Injectable Therapy Benefits, Hospice Program
7. You may refill covered prescriptions at a Medically Benefits, or Family Planning Benefits sections of your
Necessary frequency. EOC.
Outpatient Prescription Drug Exclusions 11. All Drugs related to assisted reproductive technology.
and Limitations 12. Appetite suppressants or drugs for body weight reduc-
Blue Shield does not provide coverage in the Outpatient Pre- tion. These Drugs may be covered if Medically Neces-
scription Drug Benefit for the following. You may receive sary for the treatment of morbid obesity. In these cases
coverage for certain services excluded below under other prior authorization by Blue Shield is required.
Benefits. Refer to the applicable section(s) of your EOC to 13. Contraceptive drugs or devices which do not meet all of
determine if the Plan covers Drugs under that Benefit, the following requirements:
1. Any Drug you receive while an inpatient, in a Physi- a Are FDA-approved,
cian's office, Skilled Nursing Facility or Outpatient Fa-
cility. See the Professional (Physician) Benefits and • Are ordered by a Physician or Health Care
Hospital Benefits (Facility Services) sections of your Provider,
EOC. a Are generally purchased at an outpatient phar-
2. Take home drugs received from a Hospital, Skilled macy,and
Nursing Facility, or similar facilities. See the Hospital . Are self-administered.
Benefits and Skilled Nursing Facility Benefits sections
of your EOC. I Other contraceptive methods may be covered under the
3. Unless listed as covered under this Outpatient Prescrip- Family Planning Benefits section of your EOC.
tion Drug Benefit,drugs that are available without a pre- 14. Compounded medication(s)which do not meet all of the
scription (OTC) including drugs for which there is an following requirements:
OTC drug that has the same active ingredient and dosage . The compounded medication(s)include at least
as the prescription drug.This exclusion will not apply to one Drug,
over-the-counter drugs with a United States Preventive
Services Task Force(USPSTF)rating of A or B or to fe- . There are no FDA-approved, commercially
male over-the-counter contraceptive Drugs and devices available,medically appropriate alternatives,
when prescribed by a Physician. a The compounded medication is self-adminis-
4. Drugs for which you are not legally obligated to pay,or tered,and
for which no charge is made. . Medical literature supports its use for the diag-
5. Drugs that are considered to be experimental or investi- nosis.
gational.
15. Replacement of lost,stolen or destroyed Drugs.
6. Medical devices or supplies except as listed as covered
herein.This exclusion also applies to prescription prepa- 16. If you are enrolled in a Hospice Program through a Par-
rations applied to the skin that are approved by the FDA ticipating Hospice Agency, Drugs that are Medically
as medical devices. See the Prosthetic Appliances Ben- Necessary for the palliation and management of termi-
ejus, Durable Medical Equipment Benefits, and the Or- nal illness and related conditions. These Drugs are ex-
thotics Benefits sections of your EOC. cluded from coverage under Outpatient Prescription
77
Drug Benefits and are covered under the Hospice Pro- 6. Contraceptive drugs and devices, including:
grant Benefits section of your EOC. • diaphragms,
17. Drugs prescribed for the treatment of dental conditions. • cervical caps,
This exclusion does not apply to:
• contraceptive rings,
• Antibiotics prescribed to treat infection, • contraceptive patches,
• Drugs prescribed to treat pain,or • oral contraceptives,
• Drug treatment related to surgical procedures • emergency contraceptives,and
for conditions affecting the upper/lower jaw- , female OTC contraceptive products when ordered
bone or associated bone joints. P
by a Physician or Health Care Provider;
18. Except for a covered emergency,Drugs obtained from a 7 Disposable devices that are Medically Necessary for the
pharmacy: administration of a covered outpatient prescription Drug
• Not licensed by the State Board of Pharmacy, such as syringes and inhaler spacers.
or Formulary—a list of preferred Generic and Brand Drugs
• Included on a government exclusion list. maintained by Blue Shield's Pharmacy and Therapeutics
Committee. It is designed to assist Physicians and Health
19. Immunizations and vaccinations solely for the purpose Care Providers in prescribing Drugs that are Medically Nec-
of travel. essary and cost-effective.The Formulary is updated periodi-
20. Drugs packaged in convenience kits that include non- tally.
prescription convenience items, unless the Drug is not Generic Drugs—Drugs that are approved by the Food and
otherwise available without the non-prescription com- Drug Administration(FDA)or other authorized government
ponents.This exclusion shall not apply to items used for agency as a therapeutic equivalent(i.e. contain the same ac-
the administration of diabetes or asthma Drugs. tive ingredient(s))to the Brand Drug.
21. Repackaged prescription drugs (drugs that are repack- Network Specialty Pharmacy—select Participating Phar-
aged by an entity other than the original manufacturer). macies contracted by Blue Shield to provide covered Spe-
cialty Drugs. These pharmacies offer 24-hour clinical ser-
Definitions vices and provide prompt home delivery of Specialty Drugs.
When the following terns are capitalized in this Outpatient To select a Specialty Pharmacy, you may go to
Prescription Drug Supplement, they will have the meaning httpJ/www.blueshieldca.com or call the toll-free Customer
set forth below: Service number on your Blue Shield Identification Card.
Anticancer Medications—Drags used to kill or slow the Non-Formulary Drugs—Drugs that Blue Shield's Phar-
growth of cancerous cells. macy and Therapeutics Committee has determined do not
Brand Drugs — Drugs which are FDA-approved after a have a clear advantage over Formulary Drug alternatives.
new drug application and/or registered under a brand or trade Non-Participating Pharmacy— a pharmacy which does
name by its manufacturer. not participate in the Blue Shield Pharmacy Network.These
Calendar Year Pharmacy Deductible — the amount a pharmacies are not contracted to provide services to Blue
Member pays each Calendar Year before Blue Shield pays Shield Members.
for covered Drugs under the outpatient prescription Drug Participating Pharmacy—a pharmacy which has agreed
benefit. to a contracted rate for covered Drugs for Blue Shield Mem-
Drugs — for coverage under the Outpatient Prescription bers. These pharmacies participate in the Blue Shield Phar-
Drug Benefit,Drugs are: macy Network.
1. FDA-approved medications that require a prescription Schedule 11 Controlled Substance—prescription Drugs or
either by California or Federal law; other substances that have a high potential for abuse which
2. Insulin;
may lead to severe psychological or physical dependence.
Specialty Drugs — Drugs requiring coordination of care,
3. Pen delivery systems for the administration of insulin, close monitoring, or extensive patient training for self-ad-
as Medically Necessary; ministration that cannot be met by a retail pharmacy and are
4. Diabetic testing supplies(including lancets,lancet punt- available exclusively at aNetwork Specialty Pharmacy.Spe-
ture devices, blood and urine testing strips, and test cialty Drugs may also require special handling or manufac-
tablets); turing processes (such as biotechnology), restriction to cer-
5. Over-the-counter(OTC)drugs with a United States Pre- tain Physicians or pharmacies,or reporting of certain clini-
ventive Services Task Force(USPSTF)rating of or B;
78
cal events to the FDA. Specialty Drugs are generally high
cost.
79
Contacting Blue Shield of California
For information, including information about claims submission:
Members may call Customer Service toll free at 1-888-256-1915
The hearing impaired may call Customer Service through Blue Shield's toll-free TTY
number at 711 .
For prior authorization:
Please call the Customer Service telephone number listed above.
For prior authorization of Benefits Management Program radiological services:
Please call 1-888-642-2583.
For prior authorization of inpatient Mental Health and Substance Use Disorder Ser-
vices:
Please contact the Mental Health Service Administrator at 1-877-263-9952.
Please refer to the Benefits Management Program section of this EOC for additional in-
formation on prior authorization.
Please direct correspondence to:
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
W0002421-MOO21447(01/20)
80 202001A44629
Blue Shield of California
Notice Informing Individuals about Nondiscrimination
and Accessibility Requirements
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discrim-
inate on the basis of race,color,national origin, ancestry,religion, sex,marital status, gender,gender identity,
sexual orientation, age, or disability. Blue Shield of California does not exclude people or treat them differently
because of race,color,national origin, ancestry,religion,sex, marital status,gender,gender identity,sexual ori-
entation, age,or disability.
Blue Shield of California:
• Provides aids and services at nocost to people with disabilities to communicate effectively with us
such as:
- Qualified sign language interpreters
- Written information in other formats (including large print, audio, accessible electronic formats,
and otherformats)
• Provides language services at no cost to people whose primary language is not English such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Blue Shield of California Civil Rights Coordinator.
If you believe that Blue Shield of California has failed to provide these services or discriminated in another
way on the basis of race,color,national origin, ancestry,religion,sex,marital status,gender,gender iden-
tity,sexual orientation, age, or disability,you can file a grievance with:
Blue Shield of California
Civil Rights Coordinator o
P.O. Box 629007 9
a
El Dorado Hills, CA 95762-9007
Phone: (844) 831-4133 (TTY: 711)
Fax: (844) 696-6070 m
Email: BlueShieldCivilRighfsCoordinator@blueshieldca.com
`o
You can file a grievance in person or by mail,fax,or email.If you need help filing a grievance,our Civil Rights E
Coordinator is available to help you.You can also file a civil rights complaint with the E
U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for
Civil Rights Complaint Portal, available at hffPs:Hocrportal.hhs.gov/ocr/portal/lobby.isf, or by mail or phone a
v
at: a
d
a
U.S.Department of Health and Human Services 200 `o
Independence Avenue SW. o
Room 509F, HHH Building Washing- o
ton, DC 20201
(800) 368-1019;TTY: (800) 537-7697 2
O
N
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
v
m
Blue Shield of California blue
601 121"Sfreet,Oakland,CA 94607 California
81
Notice of the Availability of Language Assistance Services
Blue Shield of California
IMPORTANT: Can you read this letter? If not,we can have somebody help you read it.
You may also be able to get this letter written in your language. For help at no cost, please
call right away at the Member/Customer Service telephone number on the back of your
Blue Shield ID card, or (866) 346-7198.
IMPORTANTE: ZPuede leer esta carta?Si no, podemos hacer que alguien le ayude a leerla.
Tambien puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor Home
inmediatamente al telefono de Servicios al miembro/cliente que se encuentra al reverso de
su tarjeta de identificaci6n de Blue Shield o al (866) 346-7198. (Spanish) g
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MAHALAGA: Nobabasa mo ba ang sulat no ito? Kung hindi, moori kaming kumuha ng
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