APPLICATION IS HEREBY MADE FOR
A GROUP HEALTH SERVICE CONTRACT TO
Blue Shield of California
(California Physicians' Service)
BY: San Francisco Health Service System Fund
1145 Market Street, 2nd Floor
San Francisco, CA 94103
This Contract, number H11054-001-006 and 008-010 (Retirees), shall be effective July 1, 2009. 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
Contractholder 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.
This application is executed in duplicate. The Contractholder shall sign, date and return this original application page
to Blue Shield of California, 50 Beale Street, 22nd Floor, San Francisco, California 94105, Attention: Customer
Contract Development. 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.
It is agreed that this application supersedes any previous application for this Contract.
Dated at (City, State)
this _______________________________ day of ________________________________________________20 _______
(Legal Name of Contractholder)
As the Contractholder, you are responsible for communicating to Subscribers as soon as possible (and in any case, no
later than 30 days after receipt) all changes in Benefits and in any provisions affecting Benefits.
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.
50 Beale Street
San Francisco, California 94105
GROUP HEALTH SERVICE CONTRACT
BLUE SHIELD ACCESS + HMO® HEALTH PLAN
San Francisco Health Service System Fund
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 July 1, 2009, for a term of one year, subject to the provisions entitled, "Changes: Entire
Group Number: H11054-001-006 and 008-010 (Retirees)
Original Effective Date: July 1, 2001
No Member 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. Benefits of this Contract are available only for Services and supplies as included
in the applicable sections of the Evidence of Coverage and Disclosure Form, 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.
TABLE OF CONTENTS
PART I. INTRODUCTION.................................................................................................................................................... C-3
PART II. DEFINITIONS........................................................................................................................................................ C-3
PART III. ELIGIBILITY........................................................................................................................................................ C-4
A. Employee Eligibility, Waiting Periods and Open Enrollment ................................................................................... C-4
B. Associated Employers ............................................................................................................................................... C-4
PART IV. GROUP RENEWAL ADVANCE NOTIFICATION............................................................................................ C-4
PART V. DUES...................................................................................................................................................................... C-5
PART VI. OUT-OF-AREA PROGRAM: THE BLUECARD® PROGRAM......................................................................... C-6
PART VII. CANCELLATION/REINSTATEMENT/GRACE PERIOD ............................................................................... C-7
A. Cancellation Without Cause ...................................................................................................................................... C-7
B. Cancellation for Non-Payment of Dues ..................................................................................................................... C-7
C. Cancellation/Rescission for Fraud, Misrepresentations or Omissions ....................................................................... C-7
D. Reinstatement of Contract ......................................................................................................................................... C-7
E. Grace Period.............................................................................................................................................................. C-7
F. Payment or Refund of Dues Upon Cancellation ........................................................................................................ C-8
G. Termination of Benefits............................................................................................................................................. C-8
H. Employer to Provide Subscribers with Notice Confirming Termination of Coverage............................................... C-8
PART VIII. GENERAL PROVISIONS ................................................................................................................................. C-9
A. Choice of Providers ................................................................................................................................................... C-9
B. Use of Masculine Pronoun......................................................................................................................................... C-9
C. Workers' Compensation............................................................................................................................................. C-9
D. Changes: Entire Contract.......................................................................................................................................... C-9
E. Statutory Requirements.............................................................................................................................................. C-9
F. Legal Process........................................................................................................................................................... C-10
G. Time of Commencement or Termination................................................................................................................. C-10
H. Records and Information to be Furnished................................................................................................................ C-10
I. Membership Cards and Evidence of Coverage and Disclosure Form Booklets....................................................... C-10
J. Inquiries and Complaints......................................................................................................................................... C-10
K. Confidentiality ......................................................................................................................................................... C-10
L. Termination of a Plan Provider Contract................................................................................................................. C-10
M. ERISA Plan Administrator ...................................................................................................................................... C-10
PART IX. CONTRACTHOLDER NOTIFICATION REQUIREMENTS........................................................................... C-11
A. Notification of Cancellation to Subscribers............................................................................................................. C-11
B. COBRA and Cal-COBRA ....................................................................................................................................... C-11
C. Individual Conversion Plan ..................................................................................................................................... C-12
PART X. AMENDMENT FOR MEDICARE PRESCRIPTION DRUG PLAN (PDP) BENEFITS .................................. C-13
EVIDENCE OF COVERAGE AND DISCLOSURE FORM................................................................................................ C-16
Refer to the Table of Contents in the Evidence of Coverage and Disclosure Form
The Evidence of Coverage and Disclosure Form includes the following optional Benefits/riders:
Outpatient Prescription Drugs
Inpatient Substance Abuse Treatment
Acupuncture and Chiropractic Services
Additional Infertility Services
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
The Evidence of Coverage and Disclosure Form is included and made part of this Contract.
PART II. DEFINITIONS
In addition to the provisions contained in the Definitions section of the Evidence of Coverage and Disclosure Form, the
following provisions apply to this Group Health Service Contract:
Employee - a retiree who meets all of the Contractholder’s eligibility requirements.
Plan Provider - shall have the meaning as set forth in the Definitions section of the attached Combined Evidence of
Coverage and Disclosure Form which is part of this Contract.
PART III. ELIGIBILITY
A. Employee Eligibility, Waiting Periods and Open Enrollment
In addition to the provisions contained in the Eligibility section of the Evidence of Coverage and Disclosure Form, the
following provisions apply to this Group Health Service Contract:
1. The date of eligibility of Employees who enroll during the initial enrollment period shall be determined as follows:
a. Eligibility for benefits shall be determined by the City and County of San Francisco Health Service System.
b. An annual Open Enrollment Period will be held.
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 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:
a. Blue Shield will accept enrollment of the Employee or Dependent retroactively for a maximum of 180 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 Evidence of Coverage, minus the Member's
Copayments as stated in the Evidence of Coverage;
b. Blue Shield will accept termination/disenrollment of the Employee or Dependent retroactive for a maximum
of 180 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.
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)
City and County of San Francisco
San Francisco Community College District
San Francisco Superior Court
San Francisco Unified School District
PART IV. GROUP RENEWAL ADVANCE NOTIFICATION
The Employer shall be notified by Blue Shield of California of its intent to renew this Group Health Service Contract at
least 120 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.
(H11054/A.1.a. & b., 2.,3.,4.,5.,C-del.)
PART V. DUES
Monthly Dues for Retirees Retiree Additional for Additional for two
and Dependents one Dependent or more Dependents
Sections 001 & 003/MP3 $1,172.22 $525.68 $961.98
Sections 002/MP2 & 004/MP4 $1,172.22 $307.06 $743.36
Sections 005/MP5 $307.06 $525.68 $961.98
Sections 006/MP6 $307.06 $307.06 $743.36
Sections 008/MP8 $307.06 $307.06 $961.98
Sections 009/MP9 $1,172.22 $307.06 $961.98
Sections 010/MPD $307.06 $307.06 $614.12
Section CC0 $578.23 $578.24 $1,058.17
B. When and Where Payable
1. Dues are payable for the entire month for new Members whose coverage effective date falls between the first day
of the month and the fifteenth day of the month. Effective dates after the fifteenth day of the month require no
payment for that month.
2. Dues are payable for the entire month for Members whose coverage is terminated on or after the sixteenth day of
that month. No dues are payable for the month the for Members whose coverage terminates before the sixteenth
day of the month.
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 therefore may be changed from time to time as set forth in Part VIII., D.
Changes Entire Contract.
D. If a government agency or other taxing authority imposes or increases a tax or other charge (other than a tax on or
measured by net income, a possessory interest tax or a sales and use tax, for each and all of which Blue Shield shall be
solely liable) upon Blue Shield or Plan Providers, (or any of their activities), or there is a cost associated in complying
with newly enacted legislation, then beginning on the effective date of that tax, charge, or legislation, Blue Shield may
calculate group's Dues to include group's share of the new or increased tax, charge, or reasonable cost of legislative
compliance. The additional Dues for the tax, the charge, or the reasonable cost of legislative compliance will be added
to the group’s Dues at the next anniversary date. The tax, charge, or reasonable cost of legislative compliance applies to
all groups and group's share is determined by dividing the number of Members enrolled through group by the total
number of members enrolled in California. Notwithstanding the foregoing, nothing contained herein shall be deemed to
impose any obligation on group to extend the term of this Contract beyond June 30, 2010, or to enter into or negotiate
with Blue Shield any agreement relating to coverage for any period beyond such date.
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 charge therefore may be made, or the Dues credit therefore may be given, as of the effective date of such change.
F. A grace period of 90 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.
(H11054/B.1 & 2, D., F.)
PART VI. OUT-OF-AREA PROGRAM: THE BLUECARD® PROGRAM
In addition to the provisions contained in the Urgent Services section of the Evidence of Coverage and Disclosure Form, the
following provisions apply to this Group Health Service Contract:
Like all Blue Cross and Blue Shield Licensees, Blue Shield of California participates in a program called “BlueCard®
Program”. Whenever Members access health care services outside the geographic area Blue Shield of California serves, the
claim for those services may be processed through BlueCard Program and presented to Blue Shield of California for payment
in conformity with network access rules of the BlueCard Program Policies then in effect (“Policies”). Under BlueCard
Program, when Members receive covered health care services within the geographic area served by an on-site Blue Cross
and/or Blue Shield Licensee (“Host Blue”), Blue Shield of California will remain responsible to the Contractholder for
fulfilling its Contract obligations. However, the Host Blue will only be responsible, in accordance with applicable BlueCard
Program Policies, if any, for providing such services as contracting with its participating providers and handling all
interaction with its participating providers. The financial terms of BlueCard Program are described generally below.
Liability Calculation Method Per Claim
The calculation of Member liability on claims for covered health care services incurred outside the geographic area Blue
Shield of California serves, and processed through BlueCard Program will be based on the lower of the provider's billed
charges or the negotiated price Blue Shield of California pays the Host Blue.
The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each
Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield of California on a claim for health
care services processed through BlueCard Program may represent:
(i) the actual price paid on the claim by the Host Blue to the health care provider (“Actual Price”), or
(ii) an estimated price, determined by the Host Blue in accordance with BlueCard Program Policies, based on the Actual
Price increased or reduced to reflect aggregate payments expected to result from settlements, withholds, any other
contingent payment arrangements and non-claims transactions with all of the Host Blue’s health care providers or one or
more particular providers (“Estimated Price”), or
(iii) an average price, determined by the Host Blue in accordance with BlueCard Program Policies, based on a billed charges
discount representing the Host Blue’s average savings expected after settlements, withholds, any other contingent
payment arrangements and non-claims transactions for all of its providers or for a specified group of providers
(“Average Price”). An Average Price may result in greater variation to the Member and Contractholder from the Actual
Price than would an Estimated Price.
Host Blues using either the Estimated Price or Average Price will, in accordance with BlueCard Program Policies,
prospectively increase or reduce the Estimated Price or Average Price to correct for over or underestimation of past prices.
However, the amount paid by the Member is a final price and will not be affected by such prospective adjustment.
Statutes in a small number of states may require a Host Blue either (1) to use a basis for calculating Member liability for
covered health care services that does not reflect the entire savings realized, or expected to be realized, on a particular claim
or (2) to add a surcharge. Should any state statutes mandate liability calculation methods that differ from the negotiated price
methodology or require a surcharge, the Host Blue would then calculate Member liability for any covered health care services
in accordance with the applicable state statute in effect at the time the Member received those services.
Return of Overpayments
Under BlueCard Program, recoveries from a Host Blue or from participating providers of a Host Blue can arise in several
ways, including but not limited to anti-fraud and abuse audits, provider/hospital audits, credit balance audits, utilization
review refunds, and unsolicited refunds. In some cases, the Host Blue will engage third parties to assist in discovery or
collection of recovery amounts. The fees of such a third party are netted against the recovery. Recovery amounts, net of fees,
if any, will be applied in accordance with applicable BlueCard Program Policies, which generally require correction on a
claim-by-claim or prospective basis.
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 within fifteen (15) days after
the due date as described in Part V. hereof, Blue Shield shall provide written Prospective Notice of Cancellation
delivered to the Employer, or mailed to the Employer's last address as shown on the records of Blue Shield, stating
when, not less than 15 days thereafter, such cancellation shall be effective. If Dues are not received within the ensuing
15 days, the Contract will be terminated for non-payment on the 15th day following the date of mailing of the
Prospective Notice of Cancellation by Blue Shield. 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.
C. Cancellation/Rescission for Fraud, Misrepresentations or Omissions
Blue Shield may terminate this Contract upon 15 days prior written notice to group, if group commits fraud or
intentionally furnishes incorrect or incomplete material information to Blue Shield.
D. Reinstatement of Contract
If payment for all delinquent Dues is received by Blue Shield more than 15 days after the date of mailing of the
Prospective Notice of Cancellation, pursuant to Part VII.B., the Contract will not be reinstated and Blue Shield will
refund such payment to the Employer within 20 business days of receipt; however, Blue Shield shall be entitled to
withhold and shall not be required to refund any amount up to the Dues accruing during the grace period described in
Paragraph E., below and in Part V.F. hereof.
E. Grace Period
The Employer shall be entitled to a grace period of 90 days for payment of Dues, as described in Part V. F. hereof. If
during a Dues 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 full month's
payment of Dues if discontinuance of coverage occurs on or after the 15th of the month. If discontinuance of coverage
occurs prior to the 15th of the month then Dues payment will be waived and refunded to the group.
PART VII. CANCELLATION/REINSTATEMENT/GRACE PERIOD
F. 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 (1) 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.
G. 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 Coverage and Extension of Benefits sections of the Evidence of Coverage and
In the event this Contract is canceled 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
Evidence of Coverage and Disclosure Form.
H. 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.
PART VIII. GENERAL PROVISIONS
In addition to the provisions contained in the Evidence of Coverage and Disclosure Form, the following provisions apply to
this Group Health Service Contract:
A. Choice of Providers
The Plan has established a network of primary care and specialty Physicians, Hospitals, Participating Hospice Agencies,
and Non-Physician Health Care Practitioners to provide Covered Services to Members. A Member must obtain or
receive approval for all Covered Services from his Personal Physician. Each Subscriber must select a Personal
Physician for himself and each of his Dependents from the list of Personal Physicians in the HMO Physician and
Hospital Directory. The Physician and Hospital Directory will be given to Members at the time of enrollment. A
Member's Personal Physician will be accessible to the Member on a 24-hour-a-day, 7-day-a-week basis, or will make
appropriate arrangements to assure coverage. Emergency Services will be provided on a 24-hour-a-day, 7-day-a-week
basis by all Plan Hospitals. The list of Providers in the Physician and Hospital Directory includes the location and
phone numbers of all Personal Physicians, Plan Hospitals, and Participating Hospice Agencies in the Personal Physician
Service Area. Members should contact Member Services for information on Plan Non-Physician Health Care
Practitioners in their Personal Physician Service Area.
B. Use of Masculine Pronoun
Whenever a masculine pronoun is used in this Contract, it shall include the feminine gender unless the context clearly
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
Except as may be required by law or regulation, the terms of this Contract or the Dues payable therefore may be
changed only upon the written agreement of the parties.
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 and the Health Insurance Portability and
Accountability Act. 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.
PART VIII. GENERAL PROVISIONS
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 of that 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. All of the Employer's records which relate to the
eligibility for and Benefits of this Plan shall be made available for inspection by Blue Shield upon reasonable notice .
I. Membership Cards and Evidence of Coverage and Disclosure Form Booklets
Membership cards will be issued by the Plan for all Subscribers, along with an Evidence of Coverage and Disclosure
Form which summarizes the Benefits of this Contract and how to obtain covered Services.
J. Inquiries and Complaints
Inquiries concerning any problems that may develop in the administration of this Contract should be directed to the Plan
at the address or telephone number indicated on page GC-1 of this Contract. (See also the Member Services section of
the Evidence of Coverage and Disclosure Form.)
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.
L. Termination of a Plan Provider Contract
1. Blue Shield shall, where possible, use best efforts to provide Employer with at least 90 days written notice prior to
termination or breach of Contract of a Plan Provider if such termination or breach may materially affect the
Employer or its Subscribers.
2. Upon termination of a Plan Provider Contract, Blue Shield shall be liable for Benefits rendered by such provider to
an eligible Member (other than for Copayments) until the authorized Services being rendered to the Member by the
former Plan Provider are completed, unless Blue Shield makes reasonable and medically appropriate provision for
the assumption of such benefits by another Plan Provider.
M. 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.
(H11054/H., I. & L.)
PART IX. CONTRACTHOLDER NOTIFICATION REQUIREMENTS
The Contractholder has various notification requirements under this Group Health Service Contract. Some of the major
Contractholder notification requirements are summarized below. Note: This summary is not to be construed as an all-
inclusive list of the notice requirements of the Contractholder under this Group Health Service Contract nor does it absolve
the Contractholder from any obligations specified elsewhere under this Group Health Service Contract.
A. Notification of Cancellation to Subscribers
If this Contract is rescinded, or canceled by either party, the Employer shall notify the Subscribers. If rescinded or
canceled by Blue Shield, the Employer shall promptly mail a copy of Blue Shield's notice of the rescission or
cancellation to each Subscriber and provide Blue Shield proof of such mailing and the date thereof. The Employer must
also inform each Subscriber regarding their right to transfer to a Blue Shield individual conversion plan.
B. COBRA and Cal-COBRA
The following provisions are applicable only when the Contractholder is subject to Title X. of the Consolidated
Omnibus Budget Reconciliation Act [COBRA] as amended or the California Continuation Benefits Replacement Act
[Cal-COBRA]. (See the Group Continuation Coverage and Extension of Benefits sections of the Evidence of Coverage
and Disclosure Form.)
Blue Shield is not the plan administrator or plan sponsor, as those terms are defined by ERISA, for any purpose,
including but not limited to COBRA, and has no responsibility for the Contractholder's COBRA administration
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.
The Contractholder is solely responsible for all aspects of the administration of Title X. of the Consolidated
Omnibus Budget Reconciliation Act [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 the Consolidated Omnibus Budget Reconciliation Act of 1985 [COBRA], as amended, apply to the
Contractholder, are as set forth below:
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
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, or the 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
PART IX. CONTRACTHOLDER NOTIFICATION REQUIREMENTS
e. 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 the COBRA law.
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 conversion rights or other
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
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
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. Individual Conversion Plan
The Contractholder is solely responsible for notifying Employees of the availability, terms and conditions of the
Individual Conversion Plan within 15 days of termination of this Contract's coverage. (See the Individual Conversion
Plan section of the Evidence of Coverage and Disclosure Form.)
PART X. AMENDMENT FOR MEDICARE
PRESCRIPTION DRUG PLAN (PDP) BENEFITS
This Amendment for Medicare Prescription Drug Plan (PDP) Benefits (“Amendment”) is to be attached to and made a part of
the Contractholder’s current Blue Shield of California Group Health Service Contract and any Amendment or Riders thereto.
The Contract is hereby amended to include this new Part XI., for “Medicare Prescription Drug Plan Benefits.”
In the event that Contractholder has elected Benefits that include prescription drug benefits for former employees who are
over 65 and are retired (“Retirees”), Blue Shield of California (“Blue Shield”) will provide such prescription drug benefits
under a Medicare Part D group prescription drug plan (“Group PDP”) to those Retirees who are eligible and accepted for
enrollment in Medicare Part D by the Centers for Medicare and Medicaid Services (“CMS”). Any Retiree who is not eligible
for Medicare Part D, or who enrolls in Medicare Part D on an individual basis, is not eligible for coverage under the Group
Contractholder acknowledges that Blue Shield must provide such Group PDP benefits in accordance with the terms of a
contract with CMS and further acknowledges that such contract imposes affirmative obligations on Blue Shield which can be
satisfied only if Contractholder agrees to certain additional obligations. Therefore, the Contractholder and Blue Shield agree
to the following additional obligations with respect to the Group PDP benefits as set forth below:
A. Enrollment Requirements. Contractholder and Blue Shield will work cooperatively to ensure that Group PDP
enrollments are handled in accordance with the CMS Enrollment and Disenrollment Guidance. If the Contractholder
elects to enroll Part D eligible Retirees in the Group PDP through a group enrollment process, Blue Shield and
Contractholder will mutually determine which party is responsible for providing CMS-required notices to Part D eligible
1. Blue Shield agrees to provide each Part D eligible Retiree with a CMS-required notice that includes the following
elements: (1) a statement indicating that the Retiree will be enrolled in the Group PDP through a group enrollment
process; (2) a statement indicating that the Retiree may affirmatively opt-out of the group enrollment, including a
description of the process for opting-out and a description of the consequences of opting-out of Group PDP
coverage; (3) a summary of benefits offered under the Group PDP; (4) an explanation of how to get more
information about the Group PDP; (5) an explanation on how to contact Medicare for information on other Part D
options that might be available to the Retiree; and (6) the information included on page 3 of Exhibit 1 of the CMS
Enrollment and Disenrollment Guidance. Blue Shield will provide this notice at least 30 days prior to the effective
date of the Retiree’s enrollment in the Group PDP. Upon Contractholder’s request, Blue Shield will provide
Contractholder with a copy of the notice that is provided to Part D eligible individuals.
2. Contractholder agrees to work cooperatively with Blue Shield to ensure the notice requirement is satisfied,
including the collection of required enrollment data as identified in Appendix 2 of the CMS Enrollment and
Disenrollment Guidance for each Part D eligible individual who is enrolled in the Group PDP and as set forth in
B. Disenrollment Requirements. In certain circumstances, a Part D eligible Retiree who is enrolled in the Group PDP
may be disenrolled on either a voluntary or involuntary basis. Contractholder and Blue Shield will work cooperatively to
ensure that Group PDP disenrollments are handled in accordance with the CMS Enrollment and Disenrollment
Guidance. At a minimum, disenrollments will be conducted in accordance with one of the following procedures:
1. For voluntary disenrollments and for involuntary disenrollments other than those described in (2.) and (3.) below,
Blue Shield will process the disenrollment under the individual disenrollment requirements specified in the CMS
Enrollment and Disenrollment Guidance. If the individual does not elect to participate in another PDP, the Retiree
may become a member of an Individual PDP offered by Blue Shield.
2. For involuntary disenrollments that occur when Contractholder determines that an Retiree is no longer eligible to
participate in the Group PDP or when Contractholder terminates this Contract, then Contractholder and Blue
Shield agree to the following:
a. Contractholder agrees that it will: (1) send a letter or notification to the affected Retiree(s) alerting them of
the termination event and describing other health plan or health insurance options that may be available
through Contractholder; and (2) provide prospective notice of enrollee ineligibility or Contract termination to
Blue Shield 60 days or as soon as reasonably possible prior to the termination date.
PART X. AMENDMENT FOR MEDICARE
PRESCRIPTION DRUG PLAN (PDP) BENEFITS
b. Blue Shield agrees that it will: (1) inform the affected Retiree(s) that they have the option to become a
member of an Individual PDP offered by Blue Shield at least 30 days prior to the date of Contract
termination or the date the individual will become ineligible for participation in the Group PDP; and (2)
provide the affected individual(s) with instructions on how to become a member of an Individual PDP
offered by Blue Shield.
3. If Contractholder elects to use a group disenrollment process, then Contractholder agrees to: (1) provide a notice
to each affected Retiree indicating that the Contractholder intends to disenroll the Retiree from the Group PDP and
including an explanation of how to contact Medicare for information on other Medicare Part D options; and (2)
collect and provide Blue Shield with all information necessary for Blue Shield to submit a complete disenrollment
request transaction to CMS.
C. Geographic Analysis. Within 30 days of the Effective Date of this Amendment, Blue Shield will conduct a geographic
analysis to identify where the most substantial portion of the Contractholder’s employees/participants reside.
Contractholder will work cooperatively with Blue Shield to ensure that this geographic analysis is completed on a timely
D. CMS Contract. Upon Contractholder’s request, Blue Shield will provide Contractholder with a copy of Blue Shield’s
contract with CMS.
E. Monthly Dues for Group PDP. Monthly dues for Retirees enrolled in the Group PDP are attached to this Amendment.
Monthly dues include coverage under both a Blue Shield medical plan and the Group PDP.
Contractholder understands that the dues charged by Blue Shield for the Group PDP may include two rate components:
(1) a Part D rate for basic prescription drug coverage, and (2) an additional rate for any enhanced prescription drug
coverage negotiated by the Contractholder (“Enhanced PDP Benefit”).
Contractholder acknowledges and agrees that these dues will be adjusted by Blue Shield every January 1 to reflect
changes in Part D premium paid by CMS. Blue Shield will provide 30 days notice to Contractholder of any change in
dues under this provision.
1. Low-Income Subsidy. Contractholder also understands that certain low income individuals may qualify for Part
D rate subsidies (“Low Income Subsidy”). Blue Shield will advise Contractholder of the two rate components
applicable for the Group PDP, and the amount of any Low Income Subsidy available for a Retiree. Contractholder
acknowledges that it may subsidize one or both rate components, subject to the following restrictions:
a. Contractholder may subsidize different rate amounts for different classes of enrollees in the Group PDP based
on reasonable and objective business criteria such as years of service, date of retirement, business location,
job category, and nature of compensation (i.e., salaried or hourly). However, the different classes of enrollees
cannot be based on eligibility for the Part D low income subsidy;
b. Contractholder may not vary the premium subsidy for Retirees within the same class of enrollees;
c. Contractholder may not charge Retirees more than the sum of the Part D premium and one hundred percent
(100%) of the additional premium for enhanced prescription drug benefits;
d. Contractholder agrees that, for all Retirees eligible for the Low Income Subsidy, the Low Income Subsidy
will first be used to reduce the portion of the Part D dues paid by the Retiree and any remaining Low Income
Subsidy will then be applied to reduce the portion of the Part D dues paid by Contractholder;
e. Contractholder agrees that, if the Low Income Subsidy for any Retiree is less than the portion of the Part D
dues paid by the Retiree, Contractholder will provide a communication to the Retiree comparing the
consequences of enrolling in the Group PDP with the consequences of enrolling in other Medicare Part D
plans that have a monthly beneficiary premium that is equal to or less than the Retiree’s Low Income Subsidy.
This communication will be provided within 30 days after Contractholder learns of the Retiree’s Low Income
2. Late Enrollment Penalty. Retirees are charged a late enrollment penalty by CMS for each month they are eligible
for and failed to enroll in a Medicare prescription drug plan, and if they did not have other creditable prescription
drug coverage during that time. CMS will subtract the base premium paid on behalf of that Retiree by the amount
PART X. AMENDMENT FOR MEDICARE
PRESCRIPTION DRUG PLAN (PDP) BENEFITS
of the Retiree’s late enrollment penalty in the premium paid to Blue Shield. In such instances, Blue Shield will
notify Contractholder of any late enrollment penalties applicable to its Retirees, and Contractholder agrees to pay
to Blue Shield the late enrollment penalty in addition to monthly dues owed. In addition, Contractholder agrees to
apportion such penalty to that Retiree’s share of cost for dues owed for the Group PDP.
F. Evidence of Coverage and Plan Description.
1. EOC. The Evidence of Coverage and Disclosure Form addendum for Group PDP coverage is attached to this
2. Plan Description. Contractholder agrees that it will timely disclose the terms and conditions of the Group PDP to
Retirees in accordance with the disclosure requirements imposed by the Employee Retirement Income Security Act
of 1974 (“ERISA”) or, if ERISA does not apply, in accordance with any disclosure requirements imposed by state
or local law. Upon Blue Shield’s request, Contractholder agrees to make copies of all such disclosures available to
G. Group PDP Formulary. Contractholder acknowledges that Blue Shield is required to utilize a different formulary for
the Group PDP that is the same as a base formulary offered by Blue Shield for a non-group prescription drug plan and
approved by CMS. Contractholder further acknowledges and agrees that Blue Shield will not modify the approved base
formulary by removing drugs, adding additional utilization management restrictions, or increasing the cost-sharing status
of a drug from the base formulary.
H. Data Provided to Blue Shield. Contractholder recognizes that some additional data elements in addition to the
standard enrollment file must be provided to Blue Shield in order to facilitate enrollment in the Group PDP. These data
elements include, but are not limited to, a Retiree’s Medicare Part A and B effective dates, Medicare Number, and
identification of whether the Retiree has other prescription drug coverage (COB). Contractholder will be responsible for
providing this data at least 30 days prior to the effective date of the Retiree’s enrollment. Failure to provide required
data in a timely manner may result in a delay of a Retiree’s effective date with CMS in the Group PDP of up to 45 days.
I. Effect of Delay in Part D Enrollment. In the event of a delay in the Retiree’s effective date by CMS for Part D
enrollment, for any reason, the Contractholder agrees to pay all dues applicable to the Group PDP, including the portion
typically paid by CMS, until such time as CMS confirms the Retiree’s effective date and transmits any payments to Blue
J. Term and Termination.
1. Term. This Amendment shall be effective as of July 1, 2009, for a term of one year, subject to the provisions of
the Contract, entitled, “Changes: Entire Contract.”
2. Termination of Group PDP Benefits. Contractholder may cancel this Amendment for Group PDP Benefits 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. Upon termination of Group PDP benefits, a Retiree may be eligible for a commercial retiree
prescription drug plan if otherwise made available by Contractholder to Retirees not enrolled in Medicare Part D
under the Contract.
3. Termination of Contract. This Amendment will automatically terminate upon cancellation of the Contract.
K. Definitions. For purposes of this Amendment, the following terms have the specified meanings:
1. “CMS Enrollment and Disenrollment Guidance” means the guidance published by CMS relating to Part D
prescription drug plan enrollment and disenrollment procedures, the full title of which is “PDP Guidance
Eligibility, Enrollment and Disenrollment.”
2. “Individual PDP” means a Medicare Part D prescription drug plan sponsored by Blue Shield that is not a Group
EVIDENCE OF COVERAGE AND DISCLOSURE FORM
An Evidence of Coverage and Disclosure Form 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
Evidence of Coverage and Disclosure Form and any applicable Supplements and are included as part of this Contract.
Note: In the Evidence of Coverage and Disclosure Form, 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.
Access+ HMO® 15 -
An Independent Member of the Blue Shield Association
Combined Evidence of Coverage and Disclosure Form
San Francisco Health Service System Fund
Group Number: H11054-001-006 and 008-010
Effective Date: July 1, 2009
Combined Evidence of Coverage
and Disclosure Form
San Francisco Health Service System Fund
15 - 100/Admit Inpatient
Effective Date: July 1, 2009
This Evidence of Coverage and Disclosure Form booklet describes the terms and conditions of coverage of your Blue Shield
Please read this Evidence of Coverage and Disclosure Form carefully and completely so that you understand which services are
covered health care services, and the limitations and exclusions that apply to your Plan. If you or your dependents have special
health care needs, you should read carefully those sections of the booklet that apply to those needs.
If you have questions about the Benefits of your Plan, or if you would like additional information, please contact Blue Shield
Member Services at the address or telephone number listed at the back of this booklet.
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; sterilization, including tubal ligation at
the time of labor and delivery; infertility treatments; or abortion. You should obtain more informa-
tion before you enroll. Call your prospective doctor, medical group, independent practice associa-
tion, or clinic, or call the health Plan at Blue Shield’s Member Services telephone number listed at
the back of this booklet to ensure that you can obtain the health care services that you need.
No person has the right to receive the Benefits of this Plan for Services or supplies furnished following termination of coverage,
except as specifically provided under the Extension of Benefits provision, and when applicable, the Group Continuation Coverage
provision in this booklet.
Benefits of this Plan are available only for Services and supplies furnished during the term it is in effect and while the individual
claiming Benefits is actually covered by this group contract.
Benefits may be modified during the term of this Plan as specifically provided under the terms of the group contract or upon re-
newal. 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 modification. There is no vested right to receive the Benefits of this
This combined Evidence of Coverage and Disclosure Form constitutes only a summary of the health
plan. The health Plan Contract must be consulted to determine the exact terms and conditions of
coverage. The Group Health Service Contract is available through your Employer or a copy can be furnished upon request.
Your Employer is familiar with this health Plan, and you may also direct questions concerning coverage or specific Plan provi-
sions to the Blue Shield Member Services Department.
The Blue Shield Access+ HMO Health Plan
Member Bill of Rights
As a Blue Shield Access+ HMO Plan Member, you have the right to:
1. Receive considerate and courteous care, with respect 10. Receive preventive health Services.
for your right to personal privacy and dignity.
11. Know and understand your medical condition, treat-
2. Receive information about all health Services available ment plan, expected outcome, and the effects these
to you, including a clear explanation of how to obtain have on your daily living.
12. Have confidential health records, except when disclo-
3. Receive information about your rights and responsibili- sure is required by law or permitted in writing by you.
ties. With adequate notice, you have the right to review your
medical record with your Personal Physician.
4. Receive information about your Access+ HMO Health
Plan, the Services we offer you, the Physicians and 13. Communicate with and receive information from
other practitioners available to care for you. Member Services in a language you can understand.
5. Select a Personal Physician and expect his/her team of 14. Know about any transfer to another Hospital, including
health workers to provide or arrange for all the care information as to why the transfer is necessary and any
that you need. alternatives available.
6. Have reasonable access to appropriate medical ser- 15. Obtain a referral from your Personal Physician for a
vices. second opinion.
7. Participate actively with your Physician in decisions 16. Be fully informed about the Blue Shield grievance pro-
regarding your medical care. To the extent permitted cedure and understand how to use it without fear of in-
by law, you also have the right to refuse treatment. terruption of health care.
8. A candid discussion of appropriate or Medically Nec- 17. Voice complaints about the Access+ HMO Health Plan
essary treatment options for your condition, regardless or the care provided to you.
of cost or benefit coverage.
18. Participate in establishing Public Policy of the Blue
9. Receive from your Physician an understanding of your Shield Access+ HMO, as outlined in your Evidence of
medical condition and any proposed appropriate or Coverage and Disclosure Form or Health Service
Medically Necessary treatment alternatives, including Agreement.
available success/outcomes information, regardless of
cost or benefit coverage, so you can make an informed
decision before you receive treatment.
The Blue Shield Access+ HMO Health Plan
As a Blue Shield Access+ HMO Plan Member, you have the responsibility to:
1. Carefully read all Blue Shield Access+ HMO materials 8. Offer suggestions to improve the Blue Shield Access+
immediately after you are enrolled so you understand HMO Plan.
how to use your Benefits and how to minimize your
9. Help Blue Shield to maintain accurate and current
out-of-pocket costs. Ask questions when necessary.
medical records by providing timely information re-
You have the responsibility to follow the provisions of
garding changes in address, family status and other
your Blue Shield Access+ HMO membership as ex-
health plan coverage.
plained in the Evidence of Coverage and Disclosure
Form or Health Service Agreement. 10. Notify Blue Shield as soon as possible if you are billed
inappropriately or if you have any complaints.
2. Maintain your good health and prevent illness by mak-
ing positive health choices and seeking appropriate 11. Select a Personal Physician for your newborn before
care when it is needed. birth, when possible, and notify Blue Shield as soon as
you have made this selection.
3. Provide, to the extent possible, information that your
Physician, and/or the Plan need to provide appropriate 12. Treat all Plan personnel respectfully and courteously as
care for you. partners in good health care.
4. Follow the treatment plans and instructions you and 13. Pay your Dues, Copayments and charges for non-
your Physician have agreed to and consider the poten- covered services on time.
tial consequences if you refuse to comply with treat-
14. For all Mental Health and substance abuse Services,
ment plans or recommendations.
follow the treatment plans and instructions agreed to by
5. Ask questions about your medical condition and make you and the Mental Health Service Administrator
certain that you understand the explanations and in- (MHSA) and obtain prior authorization for all Non-
structions you are given. Emergency Mental Health and substance abuse Ser-
6. Make and keep medical appointments and inform the
Plan Physician ahead of time when you must cancel.
7. Communicate openly with the Personal Physician you
choose so you can develop a strong partnership based
on trust and cooperation.
Table of Contents
Access+ HMO Summary of Benefits........................................................................................................................................... 5
Your Introduction to the Blue Shield Access+ HMO Health Plan................................................................................................ 12
Choice of Physicians and Providers........................................................................................................................................... 12
How to Use Your Health Plan.................................................................................................................................................... 14
Plan Benefits.............................................................................................................................................................................. 23
Principal Limitations, Exceptions, Exclusions and Reductions ................................................................................................. 36
Termination of Benefits and Cancellation Provisions................................................................................................................ 42
Group Continuation Coverage and Individual Conversion Plan ................................................................................................ 44
Other Provisions ........................................................................................................................................................................ 48
Member Services ....................................................................................................................................................................... 50
Grievance Process...................................................................................................................................................................... 50
Definitions ................................................................................................................................................................................. 52
Supplement A — Outpatient Prescription Drugs ....................................................................................................................... 58
Supplement A1 — Blue Shield of California Medicare Rx Plan .............................................................................................. 63
Supplement B — Inpatient Substance Abuse Treatment ........................................................................................................... 87
Supplement C — Acupuncture and Chiropractic Services ........................................................................................................ 88
Supplement D — Additional Infertility Services ....................................................................................................................... 90
Summary of Benefits
What follows is a summary of your Benefits and the Copayments applicable to the Benefits of your Plan. A more complete de-
scription of your Benefits is contained in the Plan Benefits section. Please be sure to read that section and the exclusions and
limitations in the Principal Limitations, Exceptions, Exclusions and Reductions section for a complete description of the Benefits
of your Plan.
You should know that all Benefits described in this summary and throughout this Evidence of Coverage and Disclosure Form
apply only when provided or authorized as described herein, except in an emergency or as otherwise specified.
Should you have any questions about your Plan, please call the Member Services Department at the number provided on the last
page of this booklet.
Note: See the end of this Summary of Benefits for important benefit footnotes.
Summary of Benefits1 Access+ HMO
Member Contract Year Deductible Deductible
(Medical Plan Deductible) Responsibility
There is no Deductible requirement under this Plan.
Member Maximum Member Maximum
Contract Year Contract Year
Copayment Responsibility3 Copayment
The Member and Family maximum Contract Year Copayment applies to all covered Services $1,000 per Member
except for those listed on the Footnotes page at the end of this Summary of Benefits. $2,000 per Family
Member Blue Shield
Maximum Lifetime Benefits Maximum Payment
There is no maximum lifetime benefit limit under this Plan. No maximum
Benefit Member Copayment
Access+ Specialist Benefits
An office visit, examination or other consultation with a Plan Specialist in the same Medical $30 per visit
Group/IPA as the Personal Physician
Conventional X-rays, lab, diagnostic tests You pay nothing
Note: See the Choice of Physicians and Providers and How to Use Your Health Plan sections
for more information and for a list of services which are not covered under this Benefit. Your
Medical Group/IPA must be an Access+ Provider in order for you to use this Benefit. Refer to
the HMO Physician and Hospital Directory or call Member Services at the number provided on
the last page of this booklet to determine whether a Medical Group or IPA is an Access+ Pro-
Note: Unless selected as an optional Benefit by your Employer, no benefits are provided. Not covered
Allergy Testing and Treatment Benefits
Office visits (includes visits for allergy serum injections) $15 per visit
Allergy serum 50% of Allowed Charges
for allergy serum
Emergency or authorized transport $50
Ambulatory Surgery Center Benefits
Ambulatory surgical Services provided on an Outpatient facility basis at an Ambulatory Surgery Cen- $50 per surgery
Note: Outpatient ambulatory surgery Services may also be obtained from a Hospital or an Ambulatory
Surgery Center that is affiliated with a Hospital, and will be paid according to the Hospital Benefits
(Facility Services) section of this Summary of Benefits.
Clinical Trial for Cancer Benefits
Covered Services for Members who have been accepted into an approved clinical trial for cancer You pay nothing
when prior authorized by Blue Shield
Note: Services for routine patient care will be paid on the same basis and at the same Benefit
levels as other covered Services shown in this Summary of Benefits.
Diabetes Care Benefits
Diabetic equipment You pay nothing
Diabetes self-management training and education $15 per visit
Durable Medical Equipment Benefits You pay nothing
Emergency Room Benefits
Emergency room Services not resulting in admission $50 per visit
Emergency room Physician Services You pay nothing
Emergency room Services resulting in admission (billed as part of Inpatient Hospital Services) $100 per admission
Note: For Emergency ambulance Services, see the Ambulance Benefits section of this Summary
Benefit Member Copayment
Family Planning and Infertility Benefits
Counseling and consulting You pay nothing
Diagnosis and treatment of cause of Infertility 50% of Allowed Charges
Tubal ligation $100 per surgery
In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a
Physician Services Copayment in an office or Outpatient facility only. If procedure is per-
formed in a facility setting, an additional Services Copayment will apply.
Elective abortion $100 per surgery
Physician Services Copayment in an office or Outpatient facility only. If procedure is per-
formed in a facility setting, an additional Services Copayment will apply.
Vasectomy $75 per surgery
Physician Services Copayment in an office or Outpatient facility only. If procedure is per-
formed in a facility setting, an additional Services Copayment will apply.
Physician office visits for diaphragm fitting $15 per visit
Injectable contraceptives when administered by a Physician $25 per injection plus $15
Hearing Aid Service
• Audiological Evaluation You pay nothing
• Hearing Aid You pay nothing
Up to a maximum of $2,500 per Member every 36 months for the hearing aid instrument and
Home Health Care Benefits
Home health care agency Services4, including home visits by a nurse, home health aide, medical $15 per visit
social worker, physical therapist, speech therapist, or occupational therapist for up to a total of
100 visits by home health care agency providers per Member per Contract Year
Medical supplies and laboratory Services to the extent the Benefits would have been provided You pay nothing
had the Member remained in the Hospital or Skilled Nursing Facility
Home Infusion/Home Injectable Therapy Benefits
Home visits by an infusion nurse (home infusion agency nursing visits are not subject to the $15 per visit
Home Health Care Contract Year visit limitation)
Home infusion/home injectable therapy provided by a Home Infusion Agency5 You pay nothing
Home self-administered injectable drugs are covered under the Outpatient Prescription Drug
Benefit if selected as an optional Benefit by your Employer, and are described in a Supplement
included with this booklet
Hospice Program Benefits (when received and authorized by a Participating Hospice
24-hour Continuous Home Care You pay nothing
General Inpatient care You pay nothing
Inpatient Respite Care You pay nothing
Routine home care You pay nothing
Pre-hospice consultative visit You pay nothing
Benefit Member Copayment
Hospital Benefits (Facility Services)
Inpatient Services, including semi-private room and board, operating room, intensive cardiac $100 per admission
care units, general nursing care, Subacute Care, drugs, medications, oxygen, blood and blood
Inpatient Hospital Services for acute medical detoxification due to substance abuse $100 per admission
Inpatient Medically Necessary skilled nursing Services including Subacute Care6 You pay nothing
Outpatient Services for surgery and necessary supplies $50 per surgery
Outpatient Services for renal dialysis, radiation therapy, chemotherapy, treatment and necessary You pay nothing
Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw Bones Benefits
Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as spe-
cifically stated and orthognathic surgery for skeletal deformity (be sure to read the Plan Benefits
section for a complete description)
Inpatient Hospital Services $100 per admission
In an Outpatient department of a Hospital $50 per surgery
In an office location $15 per visit
Mental Health and Substance Abuse Access+ Specialist Benefits
An office visit, examination or other consultation for Mental Health and substance abuse condi- $30 per visit
tions with a MHSA7 Participating Provider without a referral from the MHSA
Note: See the Mental Health and Substance Abuse Services paragraphs in the How to Use Your
Health Plan section for more information. Psychological testing and written evaluation are not
covered under this Benefit.
Mental Health and Substance Abuse Benefits
All Non-Emergency Services must be arranged through the MHSA
Initial visit $15 per visit
The Member Copayment for the initial visit to determine the condition and diagnosis of the
Member (except for Mental Health and substance abuse Services Access+ Specialist visits) will
be the Physician office visit Copayment amount. Mental Health and substance abuse Services
Access+ Specialist visits will accrue toward the 60-visit per Contract Year maximum. Initial
visits which are subsequently diagnosed as being for other than Severe Mental Illnesses or Seri-
ous Emotional Disturbances of a Child or for substance abuse care will also accrue toward the
Inpatient Hospital and professional Services $100 per admission for Hos-
Note: Unless selected as an optional Benefit by your Employer, no benefits are provided for In- pital Services
patient substance abuse Services except for Inpatient substance abuse detoxification, which is You pay nothing for Physi-
covered as any other medical Benefit shown in this Summary of Benefits. cian Services
Outpatient psychiatric Partial Hospitalization for the treatment of mental illness You pay nothing8
Outpatient Psychiatric Care for other than Severe Mental Illnesses or Serious Emotional Distur- $25 per visit
bances of a Child, and substance abuse counseling up to 60 visits per Contract Year
Outpatient Psychiatric Care, Intensive Outpatient Care and Outpatient electroconvulsive therapy $15 per visit
(ECT) for Severe Mental Illnesses of a Member of any age and of Serious Emotional Distur-
bances of a Child
Psychological testing You pay nothing
Psychosocial support through LifeReferrals 24/7 You pay nothing
Note: All Mental Health and substance abuse Services Access+ Specialist visits require an Ac-
cess+ Specialist Copayment per visit. This Copayment is in addition to any Copayments that you
may incur for any Services received in conjunction with this office visit.
Orthotic equipment and devices You pay nothing
Office visits $15 per visit
Benefit Member Copayment
Outpatient Prescription Drug Benefits
Outpatient Prescription Drug Benefits if selected as an optional Benefit by your Employer, are
described in a Supplement included with this booklet
Outpatient X-ray, Pathology and Laboratory Benefits
Outpatient X-ray, pathology and laboratory You pay nothing
PKU Related Formulas and Special Food Products Benefits
PKU related formulas and Special Food Products You pay nothing
The above Services must be prior authorized by Blue Shield.
Pregnancy and Maternity Care Benefits
Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders You pay nothing
of the fetus by means of diagnostic procedures in cases of high-risk pregnancy
All necessary Inpatient Hospital Services for normal delivery, routine newborn circumcision, $100 per admission
Cesarean section, and complications of pregnancy
Outpatient routine newborn circumcision Outpatient (in office) -
$15 per visit
Outpatient Hospital -
$50 per surgery
Preventive Health Benefits
Annual mammography and Papanicolaou test including other FDA-approved cervical cancer You pay nothing
screening tests, colorectal cancer screening, osteoporosis screening, routine lab
Routine physical exams, including well-baby, well-child, women's gynecological exams and You pay nothing
adult exams according to schedule
Medically Necessary immunizations as defined You pay nothing
Vision and hearing screening by Personal Physician for Members through age 18 You pay nothing
Health education and health promotion Services You pay nothing
Professional (Physician) Benefits
Physician office visits including surgery, chemotherapy, radiation therapy, diabetic counseling, $15 per visit
asthma self-management training, audiometry examinations when performed by a Physician or
by an audiologist at the request of a Physician, and second opinion consultations when author-
ized or OB/GYN Services from an obstetrician/gynecologist or family practice Physician who is
within the same Medical Group/IPA as the Personal Physician
Physical therapy benefits are not provided under this benefit. See below under Rehabilitation
(Physical, Occupational, and Respiratory Therapy) Benefits.
Physician home visits $25 per visit
Inpatient Physician Benefits You pay nothing
Inpatient Hospital and Skilled Nursing Facility Services by Physicians, including the Services of
a surgeon, assistant surgeon, anesthesiologist, pathologist and radiologist
Mammogram and Papanicolaou test $15 per visit
Injectable medications You pay nothing
Note: Also see Allergy Testing and Treatment Benefits in this Summary of Benefits.
Internet based consultations $10 per consultation
Prosthetic Appliances Benefits
Prosthetic equipment and devices4 (except those provided to restore and achieve symmetry inci- You pay nothing
dent to a mastectomy, which are covered under Ambulatory Surgery Center Benefits, Hospital
Benefits (Facility Services), and Professional (Physician) Benefits in the Plan Benefits section,
and specified devices following a laryngectomy, which are covered under Physician Services
Benefit Member Copayment
Rehabilitation (Physical, Occupational and Respiratory Therapy) Benefits
Rehabilitation Services by a physical, occupational, or respiratory therapist in the following set-
In the Rehabilitation unit of a Hospital for Medically Necessary days (in an Inpatient facility, You pay nothing
this Copayment is billed as part of Inpatient Hospital Services)
In the Skilled Nursing Facility Rehabilitation unit for Medically Necessary days You pay nothing
In an Outpatient department of a Hospital $15 per visit
In an office location $15 per visit
Skilled Nursing Facility Benefits
Inpatient Services in a free-standing facility, including Subacute Care, and other necessary Services You pay nothing
and supplies4 for up to 100 days per Contract Year6
Speech Therapy Benefits
Speech Therapy Services by a licensed speech pathologist or certified speech therapist in the
In the Rehabilitation unit of a Hospital for Medically Necessary days (in an Inpatient facility, You pay nothing
this Copayment is billed as part of Inpatient Hospital Services)
In the Skilled Nursing Facility Rehabilitation unit for Medically Necessary days You pay nothing
In an Outpatient department of a Hospital $15 per visit
In an office location $15 per visit
Organ Transplant Benefits for transplant of a cornea, kidney or skin and Services to obtain the
human organ transplant
Hospital Services $100 per admission
Professional (Physician) Services You pay nothing
Special Transplant Benefits for transplants of human heart, lung, heart and lung in combination,
liver, kidney and pancreas in combination, human bone marrow transplants, pediatric human
small bowel transplants, pediatric and adult human small bowel and liver transplants in combina-
tion, and Services to obtain the human transplant material
Facility Services in a Special Transplant Facility $100 per admission
Professional (Physician) Services You pay nothing
Note: Blue Shield requires prior written authorization from Blue Shield's Medical Director for
all Special Transplant Services. Also, all Services must be provided at a Special Transplant Fa-
cility designated by Blue Shield.
Urgent Services Benefits
Urgent Services outside your Personal Physician Service Area $50 per visit
Medically Necessary Out-of-Area Follow-up Care is covered.
Note: See the How to Use Your Health Plan section for more information.
Summary of Benefits1 Access+ HMO
All Benefits must be provided or authorized by your Personal Physician and/or the Medical Group/IPA except in an emer-
gency or as otherwise specified.
Before the Plan provides Benefit payments for the covered facility Services to which the Deductible applies, the Deducti-
ble must be satisfied once during the Contract Year by or on behalf of each Member separately. Payments applied to your
Contract Year Deductible accrue towards the Member Maximum Contract Year Copayment.
The Member Maximum Contract Year Copayment applies to all covered Services except for: Outpatient routine newborn
circumcision; Durable Medical Equipment; Access+ Specialist office visits including visits for Mental Health and sub-
stance abuse Services; Outpatient Psychiatric Care for other than Severe Mental Illnesses or Serious Emotional Distur-
bances of a Child and substance abuse Services excluding the initial visit; Internet based consultations; and, the following
optional Benefits: Outpatient prescription drugs; additional Infertility Benefits; chiropractic Services; acupuncture Ser-
vices; Inpatient substance abuse; and, vision plan and dental plan Benefits, if covered under this Plan.
Note: Outpatient Partial Hospitalization Psychiatric Care and Outpatient electroconvulsive therapy (ECT) Services do ap-
ply to the Member maximum Contract Year Copayment.
For care received by a Participating Hospice Agency, see Hospice Program Benefits in the Plan Benefits section.
Home infusion injectable medications require prior authorization by Blue Shield and must be obtained from Home Infusion
Agencies. See Home Infusion/Home Injectable Therapy Benefits in the Plan Benefits section for details. See the Outpa-
tient Prescription Drugs Supplement for coverage of home self-administered injectable medication, if the Member’s em-
ployer provides benefits for prescription drugs through the supplemental benefit for Outpatient Prescription Drugs.
Skilled nursing Services are limited to 100 days during any Contract Year except when received through a Hospice Pro-
gram provided by a Participating Hospice Agency. This 100-day maximum for skilled nursing Services is a combined
maximum between Hospital and Skilled Nursing Facilities.
The MHSA, Mental Health Services Administrator, is a specialized health care service plan contracted by Blue Shield of
California to administer all Mental Health and substance abuse Services.
For Outpatient Partial Hospitalization Services, an episode of care is the date from which the patient is admitted to the Par-
tial Hospitalization Program to the date the patient is discharged or leaves the Partial Hospitalization Program. Any Ser-
vices received between these two dates would constitute the episode of care. If the patient needs to be readmitted at a later
date, this would constitute another episode of care.
Note: All Services except those meeting the Emergency and Urgent Services requirements must have prior approval by the
Personal Physician, Medical Group/IPA or MHSA, including those the Member obtains after the maximum Contract Year Co-
payment has been met. The Member will be responsible for payment of services that are not authorized, those that are not an
Emergency or covered Urgent Service procedure, or Mental Health and substance abuse Services not authorized by the
MHSA. Members must obtain Services from the Plan Providers that are authorized by their Personal Physician.
Note: Copayments and charges for Services not accruing to the Member Maximum Contract Year Copayment continue to be the
Member's responsibility after the Contract Year Copayment Maximum is reached.
The Blue Shield Access+ HMO Health Plan
Combined Evidence of Coverage and Disclosure Form
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF
PROVIDERS HEALTH CARE MAY BE OBTAINED.
YOUR INTRODUCTION TO THE BLUE SHIELD *See the Mental Health and Substance Abuse Services para-
graphs in the How to Use Your Health Plan section for infor-
ACCESS+ HMO HEALTH PLAN mation.
Your interest in the Blue Shield Access+ HMO Health Plan is Note: A decision will be rendered on all requests for prior
truly appreciated. Blue Shield has served California for over authorization of services as follows:
60 years, and we look forward to serving your health care
needs. • for Urgent Services, as soon as possible to accommodate
the Member’s condition not to exceed 72 hours from re-
By choosing this Health Maintenance Organization (HMO), ceipt of the request;
you’ve selected some significant differences from not only the
other health care coverage provided by Blue Shield, but also • for other services, within 5 business days from receipt of
from that of most other health plans. the request. The treating provider will be notified of the
decision within 24 hours followed by written notice to the
Unlike some HMOs, the Access+ HMO offers you a health provider and Member within 2 business days of the deci-
Plan with a wide choice of Physicians, Hospitals and Non- sion.
Physician Health Care Practitioners. Access+ HMO Members
may also take advantage of special features such as Access+ You will have the opportunity to be an active participant in
Specialist and Access+ Satisfaction. These features are de- your own health care. We’ll help you make a personal com-
scribed fully in this booklet. mitment to maintain and, where possible, improve your health
status. Like you, we believe that maintaining a healthy life-
You will be able to select your own Personal Physician from the style and preventing illness are as important as caring for your
Blue Shield HMO Physician and Hospital Directory of general needs when you are ill or injured.
practitioners, family practitioners, internists, obstetri-
cians/gynecologists, and pediatricians. Each of your eligible As a partner in health with Blue Shield, you will receive the
Family members may select a different Personal Physician. benefit of Blue Shield’s commitment to service, an unparal-
leled record of more than 60 years.
Note: If your Plan has a per Member Contract Year Deducti-
ble requirement for facility Services, as listed on the Summary Please review this booklet which summarizes the coverage
of Benefits, then the Contract Year Deductible must be satis- and general provisions of the Blue Shield Access+ HMO.
fied for those Services to which it applies before the Plan will If you have any questions regarding the information, you may
provide Benefit payments for those covered Services. contact us through our Member Services Department at the
To determine whether a provider is a Plan Provider, consult number provided on the last page of this booklet.
the Blue Shield HMO Physician and Hospital Directory. You
may also verify this information by accessing Blue Shield’s CHOICE OF PHYSICIANS AND PROVIDERS
Internet site located at http://www.blueshieldca.com, or by
calling Member Services at the telephone number provided on SELECTING A PERSONAL PHYSICIAN
the back page of this booklet. Note: A Plan Provider’s status
may change. It is your obligation to verify whether the pro- A close Physician-patient relationship is an important ingredi-
vider you choose is a Plan Provider, in case there have been ent that helps to ensure the best medical care. Each Member
any changes since your directory was published. is therefore required to select a Personal Physician at the time
of enrollment. This decision is an important one because your
All covered Services must be provided by or arranged through Personal Physician will:
your Personal Physician, except for the following:
1. Help you decide on actions to maintain and improve your
• Services received during an Access+ Specialist visit, total health;
• OB/GYN Services provided by an obstetri- 2. Coordinate and direct all of your medical care needs;
cian/gynecologist or family practice Physician within the
same Medical Group/IPA as your Personal Physician, 3. Work with your Medical Group/IPA to arrange your re-
ferrals to Specialty Physicians, Hospitals and all other
• Emergency Services, or health Services, including requesting any prior authoriza-
tion you will need;
• Mental Health and substance abuse Services.*
4. Authorize Emergency Services when appropriate; Personal Physician coordinates with your designated Medical
Group/IPA to direct all of your medical care needs and refer
5. Prescribe those lab tests, X-rays and Services you require;
you to Specialists or Hospitals within your designated Medical
6. If you request it, assist you in obtaining prior approval Group/IPA unless because of your health condition, care is
from the Mental Health Service Administrator (MHSA) unavailable within the Medical Group/IPA.
for Mental Health and substance abuse Services*; and,
Your designated Medical Group/IPA (or Blue Shield when
*See the Mental Health and Substance Abuse Services noted on your identification card) ensures that a full panel of
paragraphs in the How to Use Your Health Plan section Specialists is available to provide for your health care needs
for information. and helps your Personal Physician manage the utilization of
your health Plan Benefits by ensuring that referrals are di-
7. Assist you in applying for admission into a Hospice Pro-
rected to Providers who are contracted with them. Medical
gram through a Participating Hospice Agency when nec-
Groups/IPAs also have admitting arrangements with Hospitals
contracted with Blue Shield in their area and some have spe-
To ensure access to Services, each Member must select a Per- cial arrangements that designate a specific Hospital as “in
sonal Physician who is located sufficiently close to the Mem- network.” Your designated Medical Group/IPA works with
ber’s home or work address to ensure reasonable access to your Personal Physician to authorize Services and ensure that
care, as determined by Blue Shield. If you do not select a that Service is performed by their in network Provider.
current Personal Physician at the time of enrollment, the Plan
The name of your Personal Physician and your designated
will designate a Personal Physician for you and you will be
Medical Group/IPA (or, “Blue Shield Administered”) is listed
notified. This designation will remain in effect until you no-
on your Access+ HMO identification card. The Blue Shield
tify the Plan of your selection of a different Personal Physi-
HMO Member Services Department can answer any questions
you may have about changing the Medical Group/IPA desig-
A Personal Physician must also be selected for a newborn or nated for your Personal Physician and whether the change
child placed for adoption, preferably prior to birth or adoption would affect your ability to receive Services from a particular
but always within 31 days from the date of birth or placement Specialist or Hospital.
for adoption. The Personal Physician selected for the month
of birth must be in the same Medical Group or IPA as the CHANGING PERSONAL PHYSICIANS OR
mother’s Personal Physician when the newborn is the natural DESIGNATED MEDICAL GROUP OR IPA
child of the mother. If the mother of the newborn is not en-
rolled as a Member or if the child has been placed with the You or your Dependent may change Personal Physicians or
Subscriber for adoption, the Personal Physician selected must designated Medical Group/IPA by calling the Member Ser-
be a Physician in the same Medical Group or IPA as the Sub- vices Department at the number provided on the last page of
scriber. If you do not select a Personal Physician within 31 this booklet or submitting a Member Change Request Form to
days following the birth or placement for adoption, the Plan the Member Services Department. Some Personal Physicians
will designate a Personal Physician from the same Medical are affiliated with more than one Medical Group/IPA. If you
Group or IPA as the natural mother or the Subscriber. This change to a Medical Group/IPA with no affiliation to your
designation will remain in effect for the first calendar month Personal Physician, you must select a new Personal Physician
during which the birth or placement for adoption occurred. If affiliated with the new Medical Group/IPA and transition any
you want to change the Personal Physician for the child after specialty care you are receiving to Specialists affiliated with
the month of birth or placement for adoption, see the para- the new Medical Group/IPA. The change will be effective the
graphs below on Changing Personal Physicians or Desig- first day of the month following notice of approval by Blue
nated Medical Group or IPA. If your child is ill during the Shield.
first month of coverage, be sure to read the information about Once your Personal Physician change is effective, all care
changing Personal Physicians during a course of treatment or must be provided or arranged by the new Personal Physician,
hospitalization. except for OB/GYN Services provided by an obstetri-
Remember that if you want your child covered beyond the 31 cian/gynecologist or family practice Physician within the same
days from the date of birth or placement for adoption, you Medical Group/IPA as your Personal Physician and Access+
must submit a written application as explained in the Eligibil- Specialist visits. Once your Medical Group/IPA change is
ity section of this Evidence of Coverage and Disclosure Form. effective, all previous authorizations for specialty care or pro-
cedures are no longer valid and must be transitioned to spe-
ROLE OF THE MEDICAL GROUP OR IPA cialists affiliated with the new Medical Group/IPA, even if
you remain with the same Personal Physician. Member Ser-
Most Blue Shield Access+ HMO Personal Physicians contract vices will assist you with the timing and choice of a new Per-
with Medical Groups or IPAs to share administrative and au- sonal Physician or Medical Group/IPA.
thorization responsibilities with them. (Of note, some Per-
sonal Physicians contract directly with Blue Shield.) Your Voluntary Medical Group/IPA changes are not permitted dur-
ing the third trimester of pregnancy or while confined to a
Hospital. The effective date of your new Medical Group/IPA RELATIONSHIP WITH YOUR PERSONAL
will be the first of the month following discharge from the PHYSICIAN
Hospital, or when pregnant, following the completion of post-
partum care. The Physician-patient relationship you and your Personal
Physician establish is very important. The best effort of your
Additionally, changing your Personal Physician or designated Personal Physician will be used to ensure that all Medically
Medical Group/IPA during a course of treatment may inter- Necessary and appropriate professional Services are provided
rupt your health care. For this reason, the effective date of to you in a manner compatible with your wishes.
your new Personal Physician or designated Medical
Group/IPA, when requested during a course of treatment, will If your Personal Physician recommends procedures or treat-
be the first of the month following the date it is medically ap- ments which you refuse, or you and your Personal Physician
propriate to transfer your care to your new Personal Physician fail to establish a satisfactory relationship, you may select a
or designated Medical Group/IPA, as determined by the Plan. different Personal Physician. Member Services can assist you
with this selection.
Exceptions must be approved by the Blue Shield Medical
Director. For information about approval for an exception to Your Personal Physician will advise you if he believes that
the above provision, please contact Member Services. there is no professionally acceptable alternative to a recom-
mended treatment or procedure. If you continue to refuse to
If your Personal Physician discontinues participation in the follow the recommended treatment or procedure, Member
Plan, Blue Shield will notify you in writing and designate a Services can assist you in the selection of another Personal
new Personal Physician for you in case you need immediate Physician.
medical care. You will also be given the opportunity to select
a new Personal Physician of your own choice within 15 days Repeated failures to establish a satisfactory relationship with a
of this notification. Your selection must be approved by Blue Personal Physician may result in termination of your cover-
Shield prior to receiving any Services under the Plan. age, but only after you have been given access to other avail-
able Personal Physicians and have been unsuccessful in estab-
CONTINUITY OF CARE BY A TERMINATED lishing a satisfactory relationship. Any such termination will
PROVIDER take place in accordance with written procedures established
by Blue Shield and only after written notice to the Member
Members who are being treated for acute conditions, serious which describes the unacceptable conduct provides the Mem-
chronic conditions, pregnancies (including immediate postpar- ber with an opportunity to respond and warns the Member of
tum care), or terminal illness; or who are children from birth the possibility of termination.
to 36 months of age; or who have received authorization from
a now-terminated provider for surgery or another procedure as
part of a documented course of treatment can request comple-
HOW TO USE YOUR HEALTH PLAN
tion of care in certain situations with a provider who is leaving
the Blue Shield provider network. Contact Member Services USE OF PERSONAL PHYSICIAN
to receive information regarding eligibility criteria and the At the time of enrollment, you will choose a Personal Physi-
policy and procedure for requesting continuity of care from a cian who will coordinate all Covered Services. You must
terminated provider. contact your Personal Physician for all health care needs in-
cluding preventive Services, routine health problems, consul-
CONTINUITY OF CARE FOR NEW MEMBERS BY tations with Plan Specialists (except as provided under Obstet-
NON-CONTRACTING PROVIDERS rical/Gynecological (OB/GYN) Physician Services, Access+
Specialist, and Mental Health and Substance Abuse Services),
Newly covered Members who are being treated for acute con- admission into a Hospice Program through a Participating
ditions, serious chronic conditions, pregnancies (including Hospice Agency, Emergency Services, Urgent Services and
immediate postpartum care), or terminal illness; or who are for hospitalization.
children from birth to 36 months of age; or who have received
authorization from a provider for surgery or another procedure The Personal Physician is responsible for providing primary
as part of a documented course of treatment can request com- care and coordinating or arranging for referral to other neces-
pletion of care in certain situations with a non-contracting sary health care Services and requesting any needed prior au-
provider who was providing services to the Member at the thorization. You should cancel any scheduled appointments at
time the Member’s coverage became effective under this Plan. least 24 hours in advance. This policy applies to appoint-
Contact Member Services to receive information regarding ments with or arranged by your Personal Physician or the
eligibility criteria and the written policy and procedure for MHSA and self-arranged appointments to an Access+ Spe-
requesting continuity of care from a non-contracting provider. cialist or for OB/GYN Services. Because your Physician has
set aside time for your appointments in a busy schedule, you
need to notify the office within 24 hours if you are unable to
keep the appointment. That will allow the office staff to offer
that time slot to another patient who needs to see the Physi-
cian. Some offices may advise you that a fee (not to exceed Group/IPA. For Mental Health care and substance abuse
your Copayment) will be charged for missed appointments Benefits, see the Mental Health and Substance Abuse para-
unless you give 24-hour advance notice or missed the ap- graphs in the How to Use Your Health Plan section for infor-
pointment because of an emergency situation. mation regarding how to access care. The Plan Specialist or
Plan Non-Physician Health Care Practitioner will provide a
If you have not selected a Personal Physician for any reason,
complete report to your Personal Physician so that your medi-
you must contact Member Services at the number provided on
cal record is complete.
the last page of this booklet, Monday through Friday, between
8 a.m. and 5 p.m. to select a Personal Physician to obtain To obtain referral for specialty Services, including lab and X-
Benefits. ray, you must first contact your Personal Physician. If the
Personal Physician determines that specialty Services are
OBSTETRICAL/GYNECOLOGICAL (OB/GYN) Medically Necessary, the Physician will complete a referral
PHYSICIAN SERVICES form and request necessary authorization. Your Personal
Physician will designate the Plan Provider from whom you
A female Member may arrange for obstetrical and/or gyneco- will receive Services.
logical (OB/GYN) Services by an obstetrician/gynecologist or
family practice Physician who is not her designated Personal When no Plan Provider is available to perform the needed
Physician without obtaining a referral. However, the obstetri- Service, the Personal Physician will refer you to a non-Plan
cian/gynecologist or family practice Physician must be in the Provider after obtaining authorization. This authorization
same Medical Group/IPA as her Personal Physician. procedure is handled for you by your Personal Physician.
Specialty Services are subject to all of the benefit and eligibil-
Obstetrical and gynecological Services are defined as: ity provisions, exclusions and limitations described in this
• Physician services related to prenatal, perinatal and post- booklet. You are responsible for contacting Blue Shield to
natal (pregnancy) care, determine that services are Covered Services, before such
services are received.
• Physician services provided to diagnose and treat disor-
ders of the female reproductive system and genitalia, SECOND MEDICAL OPINION
• Physician services for treatment of disorders of the breast, If there is a question about your diagnosis, plan of care, or
recommended treatment, including surgery, or if additional
• Routine annual gynecological examinations/annual well-
information concerning your condition would be helpful in
determining the diagnosis and the most appropriate plan of
It is important to note that services by an OB/GYN or family treatment, or if the current treatment plan is not improving
practice Physician outside of the Personal Physician’s Medical your medical condition, you may ask your Personal Physician
Group or IPA without authorization will not be covered under to refer you to another Physician for a second medical opin-
this Plan. Before making the appointment, the Member ion. The second opinion will be provided on an expedited
should call the Member Services Department at the number basis, where appropriate. If you are requesting a second opin-
provided on the last page of this booklet to confirm that the ion about care you received from your Personal Physician, the
OB/GYN or family practice Physician is in the same Medical second opinion will be provided by a Physician within the
Group/IPA as her Personal Physician. same Medical Group/IPA as your Personal Physician. If you
are requesting a second opinion about care received from a
The OB/GYN Physician Services are separate from the Ac-
specialist, the second opinion may be provided by any Plan
cess+ Specialist feature described below.
Specialist of the same or equivalent specialty. All second
opinion consultations must be authorized. Your Personal
REFERRAL TO SPECIALTY SERVICES Physician may also decide to offer such a referral even if you
Although self-referrals to Plan Specialists are allowed through do not request it. State law requires that health plans disclose
the Access+ Specialist feature described below, Blue Shield to Members, upon request, the timelines for responding to a
encourages you to receive specialty Services through a referral request for a second medical opinion. To request a copy of
from your Personal Physician. The Personal Physician is re- these timelines, you may call the Member Services Depart-
sponsible for coordinating all of your health care needs and ment at the number provided on the last page of this booklet.
can best direct you for required specialty Services. Your Per-
If your Personal Physician belongs to a Medical Group or IPA
sonal Physician will generally refer you to a Plan Specialist or
that participates as an Access+ Provider, you may also arrange
Plan Non-Physician Health Care Practitioner in the same
a second opinion visit with another Physician in the same
Medical Group or IPA as your Personal Physician, but you
Medical Group or IPA without a referral, subject to the limita-
can be referred outside the Medical Group or IPA if the type
tions described in the Access+ Specialist paragraphs later in
of specialist or Non-Physician Health Care Practitioner
needed is not available within your Personal Physician’s
Medical Group or IPA. Your Personal Physician will request
any necessary prior authorization from your Medical
ACCESS+ SPECIALIST 7. Infertility Services;
You may arrange an office visit with a Plan Specialist in the 8. Emergency Services;
same Medical Group or IPA as your Personal Physician with- 9. Urgent Services;
out a referral from your Personal Physician, subject to the
limitations described below. Access+ Specialist office visits 10. Inpatient Services, or any Services which result in a facil-
are available only to Members whose Personal Physicians ity charge, except for routine X-ray and laboratory Ser-
belong to a Medical Group or IPA that participates as an Ac- vices;
cess+ Provider. Refer to the HMO Physician and Hospital 11. Services for which the Medical Group or IPA routinely
Directory or call Blue Shield Member Services at the number allows the Member to self-refer without authorization
provided on the last page of this booklet to determine whether from the Personal Physician;
a Medical Group or IPA is an Access+ Provider. You will be
responsible for the Copayment listed in the Summary of Bene- 12. OB/GYN Services by an obstetrician/gynecologist or
fits for each Access+ Specialist visit. This Copayment is in family practice Physician within the same Medical
addition to any Copayments that you may incur for specific Group/IPA as the Personal Physician;
Benefits as described in the Summary of Benefits. Each fol- 13. Internet based consultations.
low-up office visit with the Plan Specialist which is not re-
ferred or authorized by your Personal Physician is a separate NURSEHELP 24/7 AND LIFEREFERRALS 24/7
Access+ Specialist visit and requires a separate Copayment.
NurseHelp 24/7 and LifeReferrals 24/7 programs provide
You should cancel any scheduled Access+ Specialist ap- Members with no charge, confidential, unlimited telephone
pointment at least 24 hours in advance. Unless you give 24- support for information, consultations, and referrals for health
hour advance notice or miss the appointment because of an and psychosocial issues. Members may obtain these services
emergency situation, the Physician’s office may charge you a by calling a 24-hour, toll-free telephone number. There is no
fee as much as the Access+ Specialist Copayment. charge for these services.
Note: For Access+ Specialist visits for Mental Health and These programs include:
substance abuse Services, see the following Mental Health
and Substance Abuse Services paragraphs. NurseHelp 24/7 - Members may call a registered nurse toll
free via 1-877-304-0504, 24 hours a day, to receive confiden-
The Access+ Specialist visit includes: tial advice and information about minor illnesses and injuries,
1. An examination or other consultation provided to you by chronic conditions, fitness, nutrition and other health related
a Medical Group or IPA Plan Specialist without referral topics.
from your Personal Physician; Psychosocial support through LifeReferrals 24/7 - Members
2. Conventional X-rays such as chest X-rays, abdominal flat may call 1-800-985-2405 on an unlimited, 24-hour basis for
plates, and X-rays of bones to rule out the possibility of confidential psychosocial support services. Professional
fracture (but does not include any diagnostic imaging counselors will provide support through assessment, referrals
such as CT, MRI, or bone density measurement); and counseling. Note: See the following Mental Health and
Substance Abuse Services paragraphs for important informa-
3. Laboratory Services; tion concerning this feature.
4. Diagnostic or treatment procedures which a Plan Special-
ist would regularly provide under a referral from the Per- MENTAL HEALTH AND SUBSTANCE ABUSE
sonal Physician. SERVICES
An Access+ Specialist visit does not include: Blue Shield of California has contracted with an MHSA to
1. Any services which are not covered or which are not underwrite and deliver all Mental Health and substance abuse
Medically Necessary; Services through a unique network of Mental Health Partici-
pating Providers. (See Mental Health Service Administrator
2. Services provided by a non-Access+ Provider (such as under the Definitions section for more information.) All Non-
podiatry and Physical Therapy), except for the X-ray and Emergency Mental Health and substance abuse Services, ex-
laboratory Services described above; cept for Access+ Specialist visits, must be arranged through
3. Allergy testing; the MHSA. Members do not need to arrange for Mental
Health and substance abuse Services through their Personal
4. Endoscopic procedures; Physician. (See 1. Prior Authorization paragraphs below.)
5. Any diagnostic imaging including CT, MRI, or bone den- All Mental Health and substance abuse Services, except for
sity measurement; Emergency or Urgent Services, must be provided by an
MHSA network Participating Provider. MHSA Providers are
6. Injectables, chemotherapy, or other infusion drugs, other
indicated in the Blue Shield of California Behavioral Health
than vaccines and antibiotics;
Provider Directory. Members may contact the MHSA di- Access+ Specialist visits for Mental Health and substance
rectly for information on, and to select an MHSA Provider by abuse Benefits are subject to, and accrue toward the Contract
calling 1-877-263-9952. Your Personal Physician may also Year Benefit visit maximum as shown in the Summary of
contact MHSA to obtain information regarding MHSA net- Benefits.
work Participating Providers for you.
3. Psychosocial Support through LifeReferrals 24/7
Mental Health and substance abuse Services received from a
Notwithstanding the Benefits provided under Mental Health
Provider who does not participate in the MHSA Participating
and Substance Abuse Benefits in the Plan Benefits section, the
Provider network will not be covered and all charges for these
Member also may call 1-800-985-2405 on an unlimited, 24-
services will be the Member’s responsibility.
hour basis for confidential psychosocial support services.
For complete information regarding Benefits for Mental Professional counselors will provide support through assess-
Health and substance abuse Services, see Mental Health and ment, referrals and counseling.
Substance Abuse Benefits in the Plan Benefits section.
In California, support may include, as appropriate, a referral
1. Prior Authorization to a counselor for a maximum of three no charge, face-to-face
visits within a 6-month period. These visits will not accrue to
All Mental Health and substance abuse Services must be prior
the Benefit maximums that are applicable to Mental Health
authorized by the MHSA. For prior authorization of Mental
and substance abuse Services.
Health and substance abuse Services, the Member should con-
tact the MHSA at 1-877-263-9952. In the event that the Services required of a Member are most
appropriately provided by a psychiatrist or the condition is not
Failure to receive prior authorization for Mental Health and
likely to be resolved in a brief treatment regimen, the Member
substance abuse Services as described, except for Emergency
will be referred to the MHSA intake line to access their Men-
and Urgent Services, will result in the Member being totally
tal Health and substance abuse Services which are described
responsible for all costs for these services.
under Mental Health and Substance Abuse Benefits in the
Note: The MHSA will render a decision on all requests for Plan Benefits section.
prior authorization of services as follows:
• for Urgent Services, as soon as possible to accommodate
the Member’s condition not to exceed 72 hours from re- Members who reasonably believe that they have an emer-
ceipt of the request; gency medical condition which requires an emergency re-
sponse are encouraged to appropriately use the “911” emer-
• for other services, within 5 business days from receipt of gency response system where available.
the request. The treating provider will be notified of the
decision within 24 hours followed by written notice to the Members should go to the closest Plan Hospital for Emer-
provider and Member within 2 business days of the deci- gency Services whenever possible.
If you obtain Emergency Services, you should notify your
2. Access+ Specialist visits for Mental Health and substance Personal Physician within 24 hours after care is received
abuse Services unless it was not reasonably possible to communicate with the
Personal Physician within this time limit. In such case, notice
The Access+ Specialist feature is available for all Mental should be given as soon as possible.
Health and substance abuse Services except for psychological
testing and written evaluation which are not covered under An emergency means a medical condition manifesting itself
this Benefit. by acute symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical attention
The Member may arrange for an Access+ Specialist office could reasonably be expected to result in any of the following:
visit for Mental Health and substance abuse Services without a (1) placing the Member’s health in serious jeopardy; (2) seri-
referral from the MHSA, as long as the Provider is an MHSA ous impairment to bodily functions; (3) serious dysfunction of
Participating Provider. Refer to the Blue Shield of California any bodily organ or part. If you receive non-authorized ser-
Behavioral Health Provider Directory or call the MHSA vices in a situation that Blue Shield determines was not a
Member Services at 1-877-263-9952 to determine the MHSA situation in which a reasonable person would believe that an
Participating Providers. Members will be responsible for the emergency condition existed, you will be responsible for the
Copayment listed in the Summary of Benefits for each Ac- costs of those services.
cess+ Specialist visit for Mental Health and substance abuse
Services. This Copayment is in addition to any Copayments
INPATIENT, HOME HEALTH CARE, HOSPICE
that you may incur for specific Benefits as described in the
Summary of Benefits. Each follow-up office visit for Mental PROGRAM AND OTHER SERVICES
Health and substance abuse Services which is not referred or The Personal Physician is responsible for obtaining prior au-
authorized by the MHSA is a separate Access+ Specialist visit thorization before you can be admitted to the Hospital or a
and requires a separate Copayment. Skilled Nursing Facility, including Subacute Care admissions,
except for Mental Health and substance abuse Services which tor or Hospital” tab. If you are traveling outside of the United
are described in the previous Mental Health and Substance States, you can call 1-804-673-1177 collect 24 hours a day to
Abuse Services paragraphs. The Personal Physician is respon- locate a BlueCard Worldwide® Network provider.
sible for obtaining prior authorization before you can receive
Out-of-Area Follow-up Care is covered and services may be
home health care and certain other Services or before you can ®
received through the BlueCard Program participating pro-
be admitted into a Hospice Program through a Participating
vider network or from any provider. However, authorization
Hospice Agency. If the Personal Physician determines that
by Blue Shield is required for more than two Out-of-Area
you should receive any of these Services, he or she will re-
Follow-up Care outpatient visits. Blue Shield may direct the
quest authorization. Your Personal Physician will arrange for
patient to receive the additional follow-up services from the
your admission to the Hospital, Skilled Nursing Facility, or a
Hospice Program through a Participating Hospice Agency as
well as for the provision of home health care and other Ser- If services are not received from a BlueCard provider, you
vices. may be required to pay the provider for the entire cost of the
service and submit a claim to Blue Shield HMO. Claims for
Note: For Hospital admissions for mastectomies or lymph node
Urgent Services and Out-of-Area Follow-up Care rendered
dissections, the length of Hospital stays will be determined
outside of California and not provided by a BlueCard Program
solely by the Member’s Physician in consultation with the
participating provider will be reviewed retrospectively for
Member. For information regarding length of stay for mater-
nity or maternity related Services, see Pregnancy and Mater-
nity Care Benefits in the Plan Benefits section for information Under the BlueCard Program, when you obtain health care
relative to the Newborns’ and Mothers’ Health Protection Act. services outside of California, the amount you pay, if not sub-
ject to a flat dollar Copayment, is calculated on the lower of:
URGENT SERVICES 1. The billed charges for your covered services, or
The Blue Shield Access+ HMO provides coverage for you
2. The negotiated price that the local Blue Cross and/or
and your family for your urgent service needs when you or
Blue Shield plan passes on to us.
your family are temporarily traveling outside of your Personal
Physician Service Area. Often, this "negotiated price" will consist of a simple discount
which reflects the actual price paid by the local Blue Cross
Urgent Services are defined as those Covered Services ren-
and/or Blue Shield plan. But sometimes it is an estimated
dered outside of the Personal Physician Service Area (other
price that factors into the actual price expected settlements,
than Emergency Services) which are Medically Necessary to
withholds, any other contingent payment arrangements and
prevent serious deterioration of a Member’s health resulting
non-claims transactions with your health care provider or with
from unforeseen illness, injury or complications of an existing
a specified group of providers. The negotiated price may also
medical condition, for which treatment can not reasonably be
be billed charges reduced to reflect an average expected sav-
delayed until the Member returns to the Personal Physician
ings with your health care provider or with a specified group
of providers. The price that reflects average savings may re-
Out-of-Area Follow-up Care is defined as non-emergent sult in greater variation (more or less) from the actual price
Medically Necessary out-of-area services to evaluate the paid than will the estimated price. The negotiated price will
Member’s progress after an initial Emergency or Urgent Ser- also be adjusted in the future to correct for over- or underes-
vice. timation of past prices. However, the amount you pay is con-
sidered a final price.
Outside of California
Statutes in a small number of states may require the local Blue
The Blue Shield Access+ HMO provides coverage for you
Cross and/or Blue Shield plan to use a basis for calculating
and your family for your Urgent Service needs when you or
Member liability for covered services that does not reflect the
your family are temporarily traveling outside of California.
entire savings realized, or expected to be realized, on a par-
You can receive urgent care services from any provider; how-
ticular claim or to add a surcharge. Should any state statutes
ever, using the BlueCard® Program, described below, can be
mandate Member liability calculation methods that differ from
more cost-effective and eliminate the need for you to pay for
the usual BlueCard Program method noted above or require a
the services when they are rendered and submit a claim for
surcharge, Blue Shield of California would then calculate your
reimbursement. Note: Authorization by Blue Shield is re-
liability for any covered health care services in accordance
quired for care that involves a surgical or other procedure or
with the applicable state statute in effect at the time you re-
ceived your care.
Through the BlueCard Program, you can access urgent care
For any other providers, the amount you pay, if not subject to
services across the country and around the world. While trav-
a flat dollar copayment, is calculated on the provider’s billed
eling within the United States, you can locate a BlueCard pro-
charges for your covered services.
vider any time by calling 1-800-810-BLUE (2583) or going
online at http://www.bcbs.com and selecting the “Find a Doc-
Within California situation, the Blue Shield Access+ HMO shall pay the medical
transportation provider directly.
If you are temporarily traveling within California, but are out-
side of your Personal Physician Service Area, if possible you 2. Out-of-Area Urgent Services
should call Blue Shield Member Services at the number pro-
If out-of-area Urgent Services were received from a non-
vided on the last page of this booklet for assistance in receiv-
participating BlueCard Program provider, you must submit a
ing Urgent Services through a Blue Shield of California Plan
complete claim with the Urgent Service record for payment to
Provider. You may also locate a Plan Provider by visiting our
the Plan, within 1 year after the first provision of Urgent Ser-
web site at http://www.blueshieldca.com. However, you are
vices for which payment is requested. If the claim is not sub-
not required to use a Blue Shield of California Plan Provider
mitted within this period, the Plan will not pay for those Ur-
to receive Urgent Services; you may use any provider. Re-
gent Services, unless the claim was submitted as soon as rea-
member that when you are within your Personal Physician
sonably possible as determined by the Plan. The services will
Service Area, Urgent Services must be provided or authorized
be reviewed retrospectively by the Plan to determine whether
by your Personal Physician just like all other non-emergency
the services were Urgent Services. If the Plan determines that
services of the Plan. Note: Authorization by Blue Shield is
the services would not have been authorized, and therefore,
required for care that involves a surgical or other procedure or
are not covered, it will notify the Member of that determina-
tion. The Plan will notify the Member of its determination
Follow-up care is also covered through a Blue Shield of Cali- within 30 days from receipt of the claim.
fornia Plan Provider and may also be received from any pro-
vider. However, when outside your Personal Physician Ser- MEMBER CONTRACT YEAR DEDUCTIBLE
vice Area authorization by Blue Shield HMO is required for
The following section only applies if your Plan has a Contract
more than two Out-of-Area Follow-up Care outpatient visits.
Year Deductible requirement for facility Services as listed on
Blue Shield HMO may direct the patient to receive the addi-
the Summary of Benefits.
tional follow-up services from the Personal Physician.
The Contract Year Deductible is shown in the Summary of
If services are not received from a Blue Shield of California
Benefits. The Contract Year Deductible applies only to facil-
Plan Provider, you may be required to pay the provider for the
ity charges for Inpatient Hospital Services, Skilled Nursing
entire cost of the service and submit a claim to Blue Shield
Facility Services, ambulatory surgery center Services and
HMO. Claims for Urgent Services obtained outside of your
Outpatient Hospital surgery Services.
Personal Physician Service Area within California will be
reviewed retrospectively for coverage. Before the Plan provides Benefit payments for the covered
facility Services listed below, the Deductible must be satisfied
When you receive covered Urgent Services outside your Per-
once during the Contract Year by or on behalf of each Mem-
sonal Physician within California, the amount you pay, if not
ber separately. The Deductible applies to the following cov-
subject to a flat dollar copayment, is calculated on Blue
ered facility Services:
Shield’s Allowed Charges.
1. Inpatient Hospital Services;
Claims For Emergency and Out-of-Area Urgent Services
1. Emergency 2. Skilled Nursing Facility Services;
If Emergency Services were received and expenses were in- 3. Ambulatory surgery center Services; and,
curred by the Member for services other than medical trans- 4. Outpatient Hospital Surgery Services.
portation, the Member must submit a complete claim with the
Emergency Service record for payment to the Plan, within 1 After the Contract Year Deductible is satisfied for those Ser-
year after the first provision of Emergency Services for which vices to which it applies, the Plan will provide Benefit pay-
payment is requested. If the claim is not submitted within this ments for those covered Services.
period, the Plan will not pay for those Emergency Services, The Deductible is based on Allowed Charges.
unless the claim was submitted as soon as reasonably possible
as determined by the Plan. If the services are not preauthor- Payments applied to your Contract Year Deductible accrue
ized, the Plan will review the claim retrospectively for cover- towards the Member maximum Contract Year Copayment.
age. If the Plan determines that the services received were for
a medical condition for which a reasonable person would not MEMBER MAXIMUM LIFETIME BENEFITS
reasonably believe that an emergency condition existed and There is no maximum limit on the aggregate payments by the
would not otherwise have been authorized, and, therefore, are Plan for covered Services provided under the Plan.
not covered, it will notify the Member of that determination.
The Plan will notify the Member of its determination within
30 days from receipt of the claim. In the event covered medi-
cal transportation Services are obtained in such an emergency
MEMBER MAXIMUM CONTRACT YEAR the Personal Physician or Medical Group/IPA. The
COPAYMENT Member will be responsible for payment of ser-
Your maximum Copayment responsibility each Contract Year vices that are not authorized or those that are not an
for Covered Services is shown in the Summary of Benefits. Emergency or covered out-of-Service Area Urgent
For all Plans, once a Member’s maximum responsibility has
service procedures. (See the previous Urgent Ser-
been met*, the Plan will pay 100% of Allowed Charges for vices paragraphs for information on receiving Ur-
that Member’s covered Services for the remainder of that gent Services out of the Service Area but within
Contract Year, except as described below. Additionally, for California.) Members must obtain Services from
Plans with a Member and a Family maximum responsibility, the Plan Providers that are authorized by their Per-
once the Family maximum responsibility has been met*, the
Plan will pay 100% of Allowed Charges for the Subscriber’s
sonal Physician or Medical Group/IPA and, for all
and all covered Dependents’ covered Services for the remain- Mental Health and substance abuse Services, from
der of that Contract Year, except as described below. MHSA Participating Providers. Hospice Services
*Note: Certain Services are not included in the calculation of must be received from a Participating Hospice
the maximum Contract Year Copayment. These items are Agency.
shown on the Summary of Benefits.
If your condition requires Services which are avail-
Note that Copayments and charges for Services not accruing able from the Plan, payment for services rendered
to the Member maximum Contract Year Copayment continue
by non-Plan Providers will not be considered
to be the Member’s responsibility after the Contract Year Co-
payment maximum is reached. unless the medical condition requires Emergency or
If your Plan has a per Member Contract Year Deductible re-
quirement for facility Services, as listed on the Summary of
LIMITATION OF LIABILITY
Benefits, payments applied to your Contract Year Deductible
accrue towards the Member maximum Contract Year Copay- Members shall not be responsible to Plan Providers
ment. for payment for Services if they are a Benefit of the
Note: It is your responsibility to maintain accurate records of Plan. When Covered Services are rendered by a
your Copayments and to determine and notify Blue Shield Plan Provider, the Member is responsible only for
when the Member maximum Contract Year Copayment re-
the applicable Deductible/Copayments, except as
sponsibility has been reached.
set forth in the Third Party Liability section. Mem-
You must notify Blue Shield Member Services in writing bers are responsible for the full charges for any
when you feel that your Member maximum Contract Year
Copayment responsibility has been reached. At that time, you
non-Covered Services they obtain.
must submit complete and accurate records to Blue Shield If a Plan Provider ceases to be a Plan Provider, you
substantiating your Copayment expenditures for the period in
will be notified if you are affected. The Plan will
question. Member Services addresses and telephone numbers
may be found on the last page of this booklet. make every reasonable and medically appropriate
provision to have another Plan Provider assume
LIABILITY OF SUBSCRIBER OR MEMBER FOR responsibility for Services to you. You will not be
PAYMENT responsible for payment (other than Copayments)
It is important to note that all Services except for to a former Plan Provider for any authorized Ser-
those meeting the Emergency and out-of-Service vices you receive. Once provisions have been
Area Urgent Services requirements, Access+ Spe- made for the transfer of your care, services of a
cialist visits, Hospice Program Services received former Plan Provider are no longer covered.
from a Participating Hospice Agency after the UTILIZATION REVIEW
Member has been accepted into the Hospice Pro-
State law requires that health plans disclose to Subscribers and
gram, OB/GYN Services by an obstetri-
health Plan Providers the process used to authorize or deny
cian/gynecologist or family practice Physician who health care services under the Plan.
is in the same Medical Group/IPA as the Personal
Blue Shield has completed documentation of this process
Physician, and all Mental Health and substance (“Utilization Review”) as required under Section 1363.5 of
abuse Services, must have prior authorization by the California Health and Safety Code.
To request a copy of the document describing this Utilization enrolled. Well-baby care Benefits are provided for enrolled
Review process, call the Member Services Department at the children.
number listed in the back of this booklet.
A child acquired by legal guardianship will be eligible on the
date of the court ordered guardianship, if an application is
PLAN SERVICE AREA submitted within 31 days of becoming eligible.
The Plan Service Area of this Plan is identified in the HMO
You may add newly acquired Dependents and yourself to the
Physician and Hospital Directory. You and your eligible De-
Plan by submitting an application within 31 days from the date
pendents must live or work in the Plan Service Area identified
of acquisition of the Dependent:
in those documents to enroll in this Plan and to maintain eligi-
bility in this Plan. 1. to continue coverage of a newborn or child placed for
ELIGIBILITY 2. to add a spouse after marriage or add a Domestic Partner
If you are an Employee and reside or work in the Plan Service after establishing a domestic partnership;
Area, you are eligible for coverage as a Subscriber the day
3. to add yourself and spouse following the birth of a new-
following the date you complete the applicable waiting period
born or placement of a child for adoption;
established by your Employer.
4. to add yourself and spouse after marriage;
Your spouse or Domestic Partner and all your Dependent
children who live or work in the Plan Service Area are eligible 5. to add yourself and your newborn or child placed for
at the same time. (Special arrangements may be available for adoption, following birth or placement for adoption.
Dependents who are full-time students or do not live in the
Coverage is never automatic; an application is always re-
Subscriber’s home. Please contact your Member Services
Department to request an Away From Home Care® Program
Brochure which explains these arrangements.) If both partners in a marriage or domestic partnership are
eligible to be Subscribers, children may be eligible and may
When you do not enroll yourself or your Dependents during
be enrolled as a Dependent of either parent, but not both.
the initial enrollment period and later apply for coverage, you
and your Dependents will be considered to be Late Enrollees. Enrolled Dependent children who would normally lose their
When Late Enrollees decline coverage during the initial en- eligibility under this Plan solely because of age, but who are
rollment period, they will be eligible the earlier of, 12 months incapable of self-sustaining employment by reason of a physi-
from the date of application for coverage or at the Employer’s cally or mentally disabling injury, illness, or condition, may
next Open Enrollment Period. Blue Shield will not consider have their eligibility extended under the following conditions:
applications for earlier effective dates. (1) the child must be chiefly dependent upon the Employee for
support and maintenance, and (2) the Employee must submit a
You and your Dependents will not be considered to be Late
Physician’s written certification from the Member’s Personal
Enrollees if either you or your Dependents lose coverage un-
Physician of such disabling condition. Blue Shield or the Em-
der another employer health plan and you apply for coverage
ployer will notify you at least 90 days prior to the date the
under this Plan within 31 days of the date of loss of coverage.
Dependent child would otherwise lose eligibility. You must
You will be required to furnish Blue Shield written proof of
submit the Physician’s written certification within 60 days of
the loss of coverage.
the request for such information by the Employer or by Blue
Newborn infants of the Subscriber, spouse or his or her Do- Shield. Proof of continuing disability and dependency must
mestic Partner will be eligible immediately after birth for the be submitted by the Employee as requested by Blue Shield but
first 31 days. A child placed for adoption will be eligible im- not more frequently than 2 years after the initial certification
mediately upon the date the Subscriber, spouse or Domestic and then annually thereafter.
Partner has the right to control the child’s health care. En-
The Employer must meet specified Employer eligibility, par-
rollment requests for children who have been placed for adop-
ticipation and contribution requirements to be eligible for this
tion must be accompanied by evidence of the Subscriber’s,
group Plan. See your Employer for further information.
spouse’s or Domestic Partner’s right to control the child’s
health care. Evidence of such control includes a health facility Subject to the requirements described under the Continuation
minor release report, a medical authorization form, or a relin- of Group Coverage provision in this booklet, if applicable, an
quishment form. In order to have coverage continue beyond Employee and his or her Dependents will be eligible to con-
the first 31 days without lapse, an application must be submit- tinue group coverage under this Plan when coverage would
ted to and received by Blue Shield within 31 days of the birth otherwise terminate.
or placement for adoption. Eligibility during the first 31 days
includes coverage for treatment of injury or illness only but EFFECTIVE DATE OF COVERAGE
does not include well-baby care Benefits unless the child is
Coverage will become effective for Employees and Depend-
ents who enroll during the initial enrollment period at 12:01
a.m. Pacific Time on the eligibility date established by your Coverage for a newborn child will become effective on the
Employer. date of birth. Coverage for a child placed for adoption will
become effective on the date the Subscriber, spouse or Do-
If, during the initial enrollment period, you have included your
mestic Partner has the right to control the child’s health care,
eligible Dependents on your application to Blue Shield, their
following submission of evidence of such control (a health
coverage will be effective on the same date as yours. If appli-
facility minor release report, a medical authorization form or a
cation is made for Dependent coverage within 31 days after
relinquishment form). In order to have coverage continue
you become eligible, their effective date of coverage will be
beyond the first 31 days without lapse, a written application
the same as yours.
must be submitted to and received by Blue Shield within 31
If you or your Dependent is a Late Enrollee, your coverage days. A Dependent spouse becomes eligible on the date of
will become effective the earlier of, 12 months from the date marriage. A Domestic Partner becomes eligible on the date a
you made a written request for coverage or at the Employer’s domestic partnership is established as set forth in the Defini-
next Open Enrollment Period. Blue Shield will not consider tions section of this booklet. A child acquired by legal
applications for earlier effective dates. guardianship will be eligible on the date of the court ordered
If you declined coverage for yourself and your Dependents
during the initial enrollment period because you or your De- If a court has ordered that you provide coverage for your
pendents were covered under another employer health plan, spouse, Domestic Partner or Dependent child under your
and you or your Dependents subsequently lost coverage under health benefit Plan, their coverage will become effective
that plan, you will not be considered a Late Enrollee. Cover- within 31 days of presentation of a court order by the district
age for you and your Dependents under this Plan will become attorney, or upon presentation of a court order or request by a
effective on the date of loss of coverage, provided you enroll custodial party, as described in Section 3751.5 of the Family
in this Plan within 31 days from the date of loss of coverage. Code.
You will be required to furnish Blue Shield written evidence
If you or your Dependents voluntarily discontinued coverage
of loss of coverage.
under this Plan and later request reinstatement, you or your
If you declined enrollment during the initial enrollment period Dependents will be covered the earlier of 12 months from the
and subsequently acquire Dependents as a result of marriage, date of request for reinstatement or at the Employer’s next
establishment of domestic partnership, birth or placement for Open Enrollment Period.
adoption, you may request enrollment for yourself and your
If the Member is receiving Inpatient care at a non-Plan facility
Dependents within 31 days. The effective date of enrollment
when coverage becomes effective, the Plan will provide Bene-
for both you and your Dependents will depend on how you
fits only for as long as the Member’s medical condition pre-
acquire your Dependent(s):
vents transfer to a Plan facility in the Member’s Personal Phy-
1. For marriage or domestic partnership, the effective date sician Service Area, as approved by the Plan. Unauthorized
will be the first day of the first month following receipt of continuing or follow-up care in a non-Plan facility or by non-
your request for enrollment; Plan Providers is not a Covered Service.
2. For birth, the effective date will be the date of birth; If this Plan provides Benefits within 60 days of the date of
discontinuance of the previous group health plan that was in
3. For a child placed for adoption, the effective date will be
effect with your Employer, you and all your Dependents who
the date the Subscriber, spouse, or Domestic Partner has
were validly covered under the previous group health plan on
the right to control the child’s health care.
the date of discontinuance will be eligible under this Plan.
Once each Calendar Year, your Employer may designate a
time period as an annual Open Enrollment Period. During RENEWAL OF GROUP HEALTH SERVICE
that time period, you and your Dependents may transfer from CONTRACT
another health plan sponsored by your Employer to the Ac-
cess+ HMO. A completed enrollment form, which also indi- Blue Shield of California will offer to renew the
cates the choice of Personal Physician, must be forwarded to Group Health Service Contract except in the fol-
Blue Shield within the Open Enrollment Period. Enrollment lowing instances:
becomes effective on the first day of the month following the
annual Open Enrollment Period. 1. non-payment of Dues (see Termination of
Any individual who becomes eligible at a time other than dur- Benefits and Cancellation Provisions section);
ing the annual Open Enrollment Period (e.g., newborn, child 2. fraud, misrepresentations or omissions;
placed for adoption, child acquired by legal guardianship, new
spouse or Domestic Partner, newly hired or newly transferred 3. failure to comply with Blue Shield's applicable
Employees) must complete an enrollment form within 31 days eligibility, participation or contribution rules;
of becoming eligible.
4. termination of plan type by Blue Shield;
5. Employer moves out of the Service Area; and substance abuse Services must be authorized by the
MHSA and provided by an MHSA Participating Provider.
6. association membership ceases. The Plan will not pay charges incurred for services without
authorization, except for OB/GYN Services by an obstetri-
All groups will renew subject to the above. cian/gynecologist or family practice Physician within the same
Medical Group/IPA as your Personal Physician, Access+
PREPAYMENT FEE Specialist visits, Hospice Services obtained through a Partici-
The monthly Dues for you and your Dependents are indicated pating Hospice Agency after you have been admitted into the
in your Employer’s group Contract. The initial Dues are pay- Hospice Program, and Emergency or Urgent Services ob-
able on the effective date under the group Contract, and sub- tained in accordance with the How to Use Your Health Plan
sequent Dues are payable on the same date (called the trans- section.
mittal date) of each succeeding month. Dues are payable in The determination of whether services are Medically Neces-
full on each transmittal date and must be made for all Sub- sary or are an emergency or urgent will be made by the Medi-
scribers and Dependents. cal Group/IPA or by the Plan. This determination will be
All Dues required for coverage for you and your Dependents based upon a review that is consistent with generally accepted
will be handled through your Employer, and must be paid to medical standards, and will be subject to grievance in accor-
Blue Shield of California. Payment of Dues will continue the dance with the procedures outlined in the Grievance Process
Benefits of this group Contract up to the date immediately section.
preceding the next transmittal date, but not thereafter. Except as specifically provided herein, Services are covered
The Dues payable under this Plan may be changed from time only when rendered by an individual or entity that is licensed
to time, for example, to reflect new Benefit levels. Your Em- or certified by the state to provide health care services and is
ployer will receive notice from the Plan of any changes in operating within the scope of that license or certification.
Dues at least 30 days prior to the change. Your Employer will The following are the basic health care Services covered by
then notify you immediately. the Blue Shield Access+ HMO without charge to the Member,
Note: These paragraphs on Prepayment Fee do not apply to a except for Deductible/Copayments where applicable, and as
Member who is enrolled under a Contract where monthly set forth in the Third Party Liability section. The Deducti-
Dues automatically increase, without notice, the first day of ble/Copayments are listed in the Summary of Benefits. These
the month following an age change that moves the Member Services are covered when Medically Necessary, and when
into the next higher age category. provided by the Member’s Personal Physician or other Plan
Provider or authorized as described herein, or received ac-
PLAN CHANGES cording to the provisions described under Obstetri-
cal/Gynecological (OB/GYN) Physician Services, Access+
The benefits of this Plan, including but not limited Specialist, and Mental Health and Substance Abuse Services.
to Covered Services, Deductible, Copayment, and Coverage for these Services is subject to all terms, conditions,
annual Copayment maximum amounts, are subject limitations and exclusions of the Contract, to any conditions
or limitations set forth in the benefit descriptions below, and
to change at any time. Blue Shield will provide at to the Principal Limitations, Exceptions, Exclusions and Re-
least 30 days’ written notice of any such change. ductions set forth in this booklet.
Benefits for Services or supplies furnished on or You are responsible for paying a minimum charge (Deducti-
after the effective date of any change in benefits ble/Copayment) to the Physician or provider of Services at the
will be provided based on the change. time you receive Services. The specific Deducti-
ble/Copayments, as applicable, are listed in the Summary of
ALLERGY TESTING AND TREATMENT BENEFITS
The Plan Benefits available to you under the Plan are listed in
this section. The Copayments and Deductible for these Ser- Benefits are provided for office visits for the purpose of al-
vices, if applicable, are in the Summary of Benefits. lergy testing and treatment, including injectables and serum.
The Services and supplies described here are covered only if AMBULANCE BENEFITS
they are Medically Necessary and, except for Mental Health
The Plan will pay for ambulance Services as follows:
and substance abuse Services, are provided, prescribed, or
authorized by your Personal Physician or Medical Group/IPA. 1. Emergency Ambulance Services. Emergency ambulance
Your Personal Physician will also designate the Plan Provider Services for transportation to the nearest Hospital which
from whom you must obtain authorized Services and will as- can provide such emergency care only if a reasonable
sist you in applying for admission into a Hospice Program person would have believed that the medical condition
through a Participating Hospice Agency. All Mental Health
was an emergency medical condition which required am- CLINICAL TRIAL FOR CANCER BENEFITS
Benefits are provided for routine patient care for a Member
2. Non-Emergency Ambulance Services. Medically Neces- whose Personal Physician has obtained prior authorization and
sary ambulance Services to transfer the Member from a who has been accepted into an approved clinical trial for can-
non-Plan Hospital to a Plan Hospital or between Plan fa- cer provided that:
cilities when in connection with authorized confine-
1. the clinical trial has a therapeutic intent and the Mem-
ment/admission and use of the ambulance is authorized.
ber’s treating Physician determines that participation in
AMBULATORY SURGERY CENTER BENEFITS the clinical trial has a meaningful potential to benefit the
Member with a therapeutic intent; and
Benefits are provided for Ambulatory Surgery Center Benefits
on an Outpatient facility basis at an Ambulatory Surgery Cen- 2. the Member’s treating Physician recommends participa-
ter. tion in the clinical trial; and
Note: Outpatient ambulatory surgery Services may also be 3. the Hospital and/or Physician conducting the clinical trial
obtained from a Hospital or an Ambulatory Surgery Center is a Plan Provider, unless the protocol for the trial is not
that is affiliated with a Hospital, and will be paid according to available through a Plan Provider.
Hospital Benefits (Facility Services) in the Plan Benefits sec- Services for routine patient care will be paid on the same basis
tion. and at the same Benefit levels as other Covered Services
Benefits are provided for Medically Necessary Services in shown in the Summary of Benefits.
connection with Reconstructive Surgery to correct or repair Routine patient care consists of those Services that would
abnormal structures of the body and which result in more than otherwise be covered by the Plan if those Services were not
a minimal improvement in function or appearance. In accor- provided in connection with an approved clinical trial, but
dance with the Women’s Health and Cancer Rights Act, sur- does not include:
gically implanted and other prosthetic devices (including pros-
thetic bras) and Reconstructive Surgery on either breast pro- 1. Drugs or devices that have not been approved by the fed-
vided to restore and achieve symmetry incident to a mastec- eral Food and Drug Administration (FDA);
tomy, and treatment of physical complications of a mastec- 2. Services other than health care services, such as travel,
tomy, including lymphedemas, are covered. Surgery must be housing, companion expenses, and other non-clinical ex-
authorized as described herein. Any such Services must be penses;
received while the Plan is in force with respect to the Member.
Benefits will be provided in accordance with guidelines estab- 3. Any item or service that is provided solely to satisfy data
lished by the Plan and developed in conjunction with plastic collection and analysis needs and that is not used in the
and reconstructive surgeons. clinical management of the patient;
No benefits will be provided for the following surgeries or 4. Services that, except for the fact that they are being pro-
procedures unless determined by Blue Shield to be Medically vided in a clinical trial, are specifically excluded under the
Necessary to correct or repair abnormal structures of the body Plan;
caused by congenital defects, developmental abnormalities, 5. Services customarily provided by the research sponsor
trauma, infection, tumors, or disease, and which will result in free of charge for any enrollee in the trial.
more than minimal improvement in function or appearance:
An approved clinical trial is limited to a trial that is:
1. Surgery to excise, enlarge, reduce, or change the appear-
ance of any part of the body; 1. Approved by one of the following:
2. Surgery to reform or reshape skin or bone; a. one of the National Institutes of Health;
3. Surgery to excise or reduce skin or connective tissue that b. the federal Food and Drug Administration, in the
is loose, wrinkled, sagging, or excessive on any part of form of an investigational new drug application;
c. the United States Department of Defense;
4. Hair transplantation; and
5. Upper eyelid blepharoplasty without documented signifi- d. the United States Veterans’ Administration;
cant visual impairment or symptomatology. or
This limitation shall not apply when breast reconstruction is 2. Involves a drug that is exempt under federal regulations
performed subsequent to a Medically Necessary mastectomy, from a new drug application.
including surgery on either breast to achieve or restore sym-
DIABETES CARE BENEFITS 1. Rental charges for Durable Medical Equipment in excess
of purchase price are not covered;
1. Diabetic Equipment
2. Routine maintenance or repairs, even if due to damage,
Benefits are provided for the following devices and equip-
are not covered;
ment, including replacement after the expected life of the item
and when Medically Necessary, for the management and 3. Environmental control equipment, generators, and self-
treatment of diabetes when Medically Necessary and author- help/educational devices are not covered;
4. No benefits are provided for backup or alternate items;
a. blood glucose monitors, including those designed to 5. Replacement of Durable Medical Equipment is covered
assist the visually impaired; only when it no longer meets the clinical needs of the pa-
b. Insulin pumps and all related necessary supplies; tient or has exceeded the expected lifetime of the item*.
*This does not apply to the Medically Necessary re-
c. podiatric devices to prevent or treat diabetes-related
placement of nebulizers, face masks and tubing, and peak
complications, including extra-depth orthopedic
flow monitors for the management and treatment of
asthma. (Note: See the Outpatient Prescription Drugs
d. visual aids, excluding eyewear and/or video-assisted Supplement for Benefits for asthma inhalers and inhaler
devices, designed to assist the visually impaired with spacers.)
proper dosing of Insulin. Note: See Diabetes Care Benefits in the Plan Benefits section
For coverage of diabetic testing supplies including blood and for devices, equipment and supplies for the management and
urine testing strips and test tablets, lancets and lancet puncture treatment of diabetes.
devices and pen delivery systems for the administration of If you are enrolled in a Hospice Program through a Participat-
Insulin, refer to the Outpatient Prescription Drugs Supple- ing Hospice Agency, medical equipment and supplies that are
ment. reasonable and necessary for the palliation and management
2. Diabetes Self-Management Training of Terminal Illness and related conditions are provided by the
Hospice Agency. For information see Hospice Program
Diabetes Outpatient self-management training, education and Benefits in the Plan Benefits section.
medical nutrition therapy that is Medically Necessary to en-
able a Member to properly use the diabetes-related devices EMERGENCY ROOM BENEFITS
and equipment and any additional treatment for these Services
1. Emergency Services. Members who reasonably believe
if directed or prescribed by the Member’s Personal Physician
that they have an emergency medical or Mental Health
and authorized. These Benefits shall include, but not be lim-
condition which requires an emergency response are en-
ited to, instruction that will enable diabetic patients and their
couraged to appropriately use the "911" emergency re-
families to gain an understanding of the diabetic disease proc-
sponse system where available. The Member should no-
ess, and the daily management of diabetic therapy, in order to
tify the Personal Physician or the MHSA by phone within
thereby avoid frequent hospitalizations and complications.
24 hours of the commencement of the Emergency Ser-
DURABLE MEDICAL EQUIPMENT BENEFITS vices, or as soon as it is medically possible for the Mem-
ber to provide notice. The services will be reviewed ret-
Medically Necessary Durable Medical Equipment for Activi- rospectively by the Plan to determine whether the ser-
ties of Daily Living, supplies needed to operate Durable vices were for a medical condition for which a reasonable
Medical Equipment, oxygen and its administration, and person would have believed that they had an emergency
ostomy and medical supplies to support and maintain gastroin- medical condition. The Emergency Services Copayment
testinal, bladder or respiratory function are covered. When does not apply if the Member is admitted directly to the
authorized as Durable Medical Equipment, other covered Hospital as an Inpatient from the emergency room.
items include peak flow monitor for self-management of
asthma, the glucose monitor for self-management of diabetes, 2. Continuing or Follow-up Treatment. The Plan will pro-
apnea monitors for management of newborn apnea, and the vide benefits for care in a non-Plan Hospital only for as
home prothrombin monitor for specific conditions as deter- long as the Member’s medical condition prevents transfer
mined by Blue Shield. Benefits are provided at the most cost- to a Plan Hospital in the Member’s Personal Physician
effective level of care that is consistent with professionally Service Area, as approved by the Medical Group/IPA or
recognized standards of practice. If there are 2 or more pro- by Blue Shield. Unauthorized continuing or follow-up
fessionally recognized items equally appropriate for a condi- care after the initial emergency has been treated in a non-
tion, Benefits will be based on the most cost-effective item. Plan Hospital, or by a non-Plan Provider is not a covered
Medically Necessary Durable Medical Equipment for Activi-
ties of Daily Living is covered as described in this section,
except as noted below:
FAMILY PLANNING AND INFERTILITY BENEFITS not to exceed 8 hours per day by any of the following profes-
1. Family Planning Counseling.
1. Registered nurse;
2. Infertility Services. Infertility Services, except as ex-
cluded in the Principal Limitations, Exceptions, Exclu- 2. Licensed vocational nurse;
sions and Reductions section, including professional,
3. Physical therapist, occupational therapist, or speech
Hospital, ambulatory surgery center, and ancillary Ser-
vices to diagnose and treat the cause of Infertility. Any
services related to the harvesting or stimulation of the 4. Certified home health aide in conjunction with the Ser-
human ovum (including medications, laboratory and ra- vices of 1., 2. or 3. above;
diology service) are not covered.
5. Medical social worker.
3. Tubal Ligation.
For the purpose of this Benefit, visits from home health aides
4. Elective Abortion. of 4 hours or less shall be considered as one visit.
5. Vasectomy. In conjunction with the professional Services rendered by a
home health agency, medical supplies used during a covered
6. Physician office visits for diaphragm fitting.
visit by the home health agency necessary for the home health
7. Injectable contraceptives when administered by a Physi- care treatment plan, and related laboratory Services are cov-
cian. ered to the extent the Benefits would have been provided had
the Member remained in the Hospital or Skilled Nursing Fa-
HEARING AID SERVICES cility.
1. Audiological Evaluation This Benefit does not include medications, drugs, or in-
To measure the extent of hearing loss and a hearing aid jectables covered under the Home Infusion/Home Injectable
evaluation to determine the most appropriate make and Therapy Benefit or under the supplemental Benefit for Outpa-
model of hearing aid. tient Prescription Drugs.
Skilled Nursing Services. A level of care that includes ser-
2. Hearing Aid
vices that can only be performed safely and correctly by a
Monaural or binaural including ear mold(s), the hearing aid licensed nurse (either a registered nurse or a licensed voca-
instrument, the initial battery, cords and other ancillary tional nurse).
equipment. Includes visits for fitting, counseling, adjust-
Note: See the Hospice Program Benefits section for informa-
ments, repairs, etc. at no charge for a one-year period fol-
tion about when a Member is admitted into a Hospice Pro-
lowing the provision of a covered hearing aid.
gram and a specialized description of Skilled Nursing Ser-
Excludes the purchase of batteries or other ancillary equip- vices for hospice care.
ment, except those covered under the terms of the initial
Note: For information concerning diabetes self-management
hearing aid purchase and charges for a hearing aid which
training, see Diabetes Care Benefits in the Plan Benefits sec-
exceed specifications prescribed for correction of a hearing
loss. Excludes replacement parts for hearing aids, repair of
hearing aid after the covered one-year warranty period and HOME INFUSION/HOME INJECTABLE THERAPY BENEFITS
replacement of a hearing aid more than once in any period
of 36 months. Also excludes surgically implanted devices. Benefits are provided for home infusion and IV injectable
therapy, including home infusion agency Skilled Nursing Ser-
To receive these services, you may either contact your Per- vices, parenteral nutrition Services and associated supple-
sonal Physician to obtain a referral or self-refer to an Ac- ments, medical supplies used during a covered visit, pharma-
cess+ Specialist as described under the Access+ Specialist ceuticals administered intravenously, related laboratory Ser-
section of this booklet. vices, and for Medically Necessary, FDA approved injectable
medications when prescribed by the Personal Physician and
HOME HEALTH CARE BENEFITS
prior authorized, and when provided by a Home Infusion
Benefits are provided for home health care Services when the Agency.
Services are Medically Necessary, ordered by the Personal
This Benefit does not include medications, drugs, insulin,
Physician, and authorized. Visits by home health care agency
insulin syringes or Home Self-Administered Injectables cov-
providers are limited to a combined visit maximum during any
ered under the supplemental Benefit for Outpatient Prescrip-
Contract Year as shown in the Summary of Benefits.
Intermittent and part-time home visits by a home health
Skilled Nursing Services are defined as a level of care that
agency to provide Skilled Nursing Services and other skilled
includes Services that can only be performed safely and cor-
Services are covered up to 4 visits per day, 2 hours per visit
rectly by a licensed nurse (either a registered nurse or a li- 9. Pharmaceuticals, medical equipment, and supplies that
censed vocational nurse). are reasonable and necessary for the palliation and man-
agement of Terminal Illness and related conditions.
HOSPICE PROGRAM BENEFITS
10. Physical Therapy, Occupational Therapy, and speech-
Benefits are provided for the following Services through a language pathology Services for purposes of symptom
Participating Hospice Agency when an eligible Member re- control, or to enable the enrollee to maintain Activities of
quests admission to and is formally admitted to an approved Daily Living and basic functional skills.
Hospice Program. The Member must have a Terminal Illness
as determined by their Plan Provider’s certification and the 11. Nursing care Services are covered on a continuous basis
admission must receive prior approval from Blue Shield. for as much as 24 hours a day during Periods of Crisis as
Note: Members with a Terminal Illness who have not elected necessary to maintain a Member at home. Hospitaliza-
to enroll in a Hospice Program can receive a pre-Hospice con- tion is covered when the Interdisciplinary Team makes
sultative visit from a Participating Hospice Agency. Covered the determination that skilled nursing care is required at a
Services are available on a 24-hour basis to the extent neces- level that can’t be provided in the home. Either Home-
sary to meet the needs of individuals for care that is reason- maker Services or Home Health Aide Services or both
able and necessary for the palliation and management of Ter- may be covered on a 24-hour continuous basis during Pe-
minal Illness and related conditions. Members can continue to riods of Crisis but the care provided during these periods
receive Covered Services that are not related to the palliation must be predominantly nursing care.
and management of the Terminal Illness from the appropriate 12. Respite Care Services are limited to an occasional basis
Plan Provider. Member Copayments when applicable are and to no more than 5 consecutive days at a time.
paid to the Participating Hospice Agency.
Members are allowed to change their Participating Hospice
Note: Hospice services provided by a non-Participating Hos- Agency only once during each Period of Care. Members can
pice Agency are not covered except in certain circumstances receive care for two 90-day periods followed by an unlimited
in counties in California in which there are no Participating number of 60-day periods. The care continues through an-
Hospice Agencies. If Blue Shield prior authorizes Hospice other Period of Care if the Plan Provider recertifies that the
Program Services from a non-contracted Hospice, the Mem- Member is Terminally ill.
ber’s Copayment for these Services will be the same as the
Copayments for Hospice Program Services when received and DEFINITIONS
authorized by a Participating Hospice Agency.
Bereavement Services – Services available to the immediate
All of the Services listed below must be received through the surviving family members for a period of at least 1 year after
Participating Hospice Agency. the death of the Member. These Services shall include an
1. Pre-Hospice consultative visit regarding pain and symp- assessment of the needs of the bereaved family and the devel-
tom management, Hospice and other care options includ- opment of a care plan that meets these needs, both prior to,
ing care planning (Members do not have to be enrolled in and following the death of the Member.
the Hospice Program to receive this Benefit). Continuous Home Care – home care provided during a Pe-
2. Interdisciplinary Team care with development and main- riod of Crisis. A minimum of 8 hours of continuous care,
tenance of an appropriate Plan of Care and management during a 24-hour day, beginning and ending at midnight is
of Terminal Illness and related conditions. required. This care could be 4 hours in the morning and an-
other 4 hours in the evening. Nursing care must be provided
3. Skilled Nursing Services, certified Health Aide Services, for more than half of the Period of Care and must be provided
and Homemaker Services under the supervision of a by either a registered nurse or licensed practical nurse. Home-
qualified registered nurse. maker Services or Home Health Aide Services may be pro-
4. Bereavement Services. vided to supplement the nursing care. When fewer than 8
hours of nursing care are required, the Services are covered as
5. Social Services/Counseling Services with medical Social routine home care rather than Continuous Home Care.
Services provided by a qualified social worker. Dietary
counseling, by a qualified provider, shall also be provided Home Health Aide Services – Services providing for the
when needed. personal care of the Terminally Ill Member and the perform-
ance of related tasks in the Member’s home in accordance
6. Medical Direction with the medical director being also with the Plan of Care in order to increase the level of comfort
responsible for meeting the general medical needs for the and to maintain personal hygiene and a safe, healthy environ-
Terminal Illness of the Members to the extent that these ment for the patient. Home Health Aide Services shall be
needs are not met by the Personal Physician. provided by a person who is certified by the state Department
7. Volunteer Services. of Health Services as a home health aide pursuant to Chapter
8 of Division 2 of the Health and Safety Code.
8. Short-term Inpatient care arrangements.
Homemaker Services – Services that assist in the mainte- Hospice care even if the Member lives longer than 1 year. A
nance of a safe and healthy environment and Services to en- Period of Care starts the day the Member begins to receive
able the Member to carry out the treatment plan. Hospice care and ends when the 90- or 60-day period has
Hospice Service or Hospice Program – a specialized form
of interdisciplinary health care that is designed to provide Period of Crisis – a period in which the Member requires
palliative care, alleviate the physical, emotional, social, and continuous care to achieve palliation or management of acute
spiritual discomforts of a Member who is experiencing the last medical symptoms.
phases of life due to the existence of a Terminal Disease, to
Plan of Care – a written plan developed by the attending
provide supportive care to the primary caregiver and the fam-
Physician and surgeon, the “medical director” (as defined
ily of the Hospice patient, and which meets all of the follow-
under “Medical Direction”) or Physician and surgeon desig-
nee, and the Interdisciplinary Team that addresses the needs of
1. Considers the Member and the Member’s family in addi- a Member and family admitted to the Hospice Program. The
tion to the Member, as the unit of care. Hospice shall retain overall responsibility for the development
and maintenance of the Plan of Care and quality of Services
2. Utilizes an Interdisciplinary Team to assess the physical,
medical, psychological, social, and spiritual needs of the
Member and the Member’s family. Respite Care Services – short-term Inpatient care provided to
the Member only when necessary to relieve the family mem-
3. Requires the Interdisciplinary Team to develop an overall
bers or other persons caring for the Member.
Plan of Care and to provide coordinated care which em-
phasizes supportive Services, including, but not limited Skilled Nursing Services – nursing Services provided by or
to, home care, pain control, and short-term Inpatient Ser- under the supervision of a registered nurse under a Plan of
vices. Short-term Inpatient Services are intended to en- Care developed by the Interdisciplinary Team and the Mem-
sure both continuity of care and appropriateness of Ser- ber’s Plan Provider to a Member and his family that pertain to
vices for those Members who cannot be managed at the palliative, Services required by a Member with a Terminal
home because of acute complications or the temporary Illness. Skilled Nursing Services include, but are not limited
absence of a capable primary caregiver. to, Member assessment, evaluation, and case management of
the medical nursing needs of the Member, the performance of
4. Provides for the palliative medical treatment of pain and
prescribed medical treatment for pain and symptom control,
other symptoms associated with a Terminal Disease, but
the provision of emotional support to both the Member and
does not provide for efforts to cure the disease.
his family, and the instruction of caregivers in providing per-
5. Provides for Bereavement Services following the Mem- sonal care to the enrollee. Skilled Nursing Services provide
ber’s death to assist the family to cope with social and for the continuity of Services for the Member and his family
emotional needs associated with the death of the Member. and are available on a 24-hour on-call basis.
6. Actively utilizes volunteers in the delivery of Hospice Social Service/Counseling Services – those counseling and
Services. spiritual Services that assist the Member and his family to
minimize stresses and problems that arise from social, eco-
7. Provides Services in the Member’s home or primary
nomic, psychological, or spiritual needs by utilizing appropri-
place of residence to the extent appropriate based on the
ate community resources, and maximize positive aspects and
medical needs of the Member.
opportunities for growth.
8. Is provided through a Participating Hospice.
Terminal Disease or Terminal Illness – a medical condition
Interdisciplinary Team – the Hospice care team that in- resulting in a prognosis of life of 1 year or less, if the disease
cludes, but is not limited to, the Member and the Member’s follows its natural course.
family, a Physician and surgeon, a registered nurse, a social
Volunteer Services – Services provided by trained Hospice
worker, a volunteer, and a spiritual caregiver.
volunteers who have agreed to provide service under the di-
Medical Direction – Services provided by a licensed Physi- rection of a Hospice staff member who has been designated by
cian and surgeon who is charged with the responsibility of the Hospice to provide direction to Hospice volunteers. Hos-
acting as a consultant to the Interdisciplinary Team, a consult- pice volunteers may provide support and companionship to
ant to the Member’s Personal Physician, as requested, with the Member and his family during the remaining days of the
regard to pain and symptom management, and liaison with Member’s life and to the surviving family following the Mem-
Physicians and surgeons in the community. For the purposes ber’s death.
of this section, the person providing these Services shall be
referred to as the “medical director”. HOSPITAL BENEFITS (FACILITY SERVICES)
Period of Care – the time when the Personal Physician recer- The following Hospital Services customarily furnished by a
tifies that the Member still needs and remains eligible for Hospital will be covered when Medically Necessary and au-
1. Inpatient Hospital Services include: all skilled nursing Services whether in a Hospital or a
Skilled Nursing Facility;
a. Semi-private room and board, unless a private room
is Medically Necessary; o. Rehabilitation when furnished by the Hospital and
b. General nursing care, and special duty nursing when
Medically Necessary; p. Medically Necessary Services in connection with
Reconstructive Surgery to correct or repair abnormal
c. Meals and special diets when Medically Necessary; structures of the body and which result in more than
d. Intensive care Services and units; a minimal improvement in function or appearance.
In accordance with the Women’s Health and Cancer
e. Operating room, special treatment rooms, delivery Rights Act, surgically implanted and other prosthetic
room, newborn nursery and related facilities; devices (including prosthetic bras) and Reconstruc-
tive Surgery on either breast provided to restore and
f. Hospital ancillary Services including diagnostic achieve symmetry incident to a mastectomy, and
laboratory, X-ray Services and therapy Services; treatment of physical complications of a mastectomy,
g. Drugs, medications, biologicals, and oxygen adminis- including lymphedemas, are covered. Surgery must
tered in the Hospital, and up to 3 days' supply of drugs be authorized as described herein. Any such Ser-
supplied upon discharge by the Plan Physician for the vices must be received while the Plan is in force with
purpose of transition from the Hospital to home; respect to the Member. Benefits will be provided in
accordance with guidelines established by the Plan
h. Surgical and anesthetic supplies, dressings and cast and developed in conjunction with plastic and recon-
materials, surgically implanted devices and Prosthe- structive surgeons.
ses, other medical supplies and medical appliances, No benefits will be provided for the following sur-
and equipment administered in the Hospital; geries or procedures unless determined by Blue
i. Administration of blood, blood plasma including the Shield to be Medically Necessary to correct or repair
cost of blood, blood plasma, and in-Hospital blood abnormal structures of the body caused by congenital
processing; defects, developmental abnormalities, trauma, infec-
tion, tumors, or disease, and which will result in
j. Radiation therapy, chemotherapy, and renal dialysis; more than minimal improvement in function or ap-
k. Subacute Care;
(1) Surgery to excise, enlarge, reduce, or change the
l. Inpatient Services including general anesthesia and appearance of any part of the body;
associated facility charges in connection with dental
procedures when hospitalization is required because (2) Surgery to reform or reshape skin or bone;
of an underlying medical condition or clinical status (3) Surgery to excise or reduce skin or connective
and the Member is under the age of 7 or develop- tissue that is loose, wrinkled, sagging, or exces-
mentally disabled regardless of age or when the sive on any part of the body;
Member’s health is compromised and for whom
general anesthesia is Medically Necessary regardless (4) Hair transplantation; and
of age. Excludes dental procedures and services of a (5) Upper eyelid blepharoplasty without docu-
dentist or oral surgeon; mented significant visual impairment or symp-
m. Medically Necessary Inpatient substance abuse de-
toxification Services required to treat potentially life- This limitation shall not apply when breast recon-
threatening symptoms of acute toxicity or acute struction is performed subsequent to a Medically
withdrawal are covered when a covered Member is Necessary mastectomy, including surgery on either
admitted through the emergency room or when breast to achieve or restore symmetry.
Medically Necessary Inpatient substance abuse de-
Note: See Hospice Program Benefits in the Plan Benefits sec-
toxification is prior authorized;
tion for Inpatient Hospital Services provided under the hos-
n. Medically Necessary Inpatient skilled nursing Ser- pice program Services Benefit.
vices, including Subacute Care. Note: These Ser- 2. Outpatient Hospital Services:
vices are limited to the day maximum as shown in
the Summary of Benefits during any Contract Year a. Services and supplies for treatment (including dialy-
except when received through a Hospice Program sis, radiation and chemotherapy) or surgery in an
provided by a Participating Hospice Agency. This Outpatient Hospital setting.
day maximum is a combined Benefit maximum for
b. Services for general anesthesia and associated facil- LIMITED TRANSGENDER BENEFIT
ity charges in connection with dental procedures
The Access+ HMO Plan provides coverage for the following
when performed in a Hospital Outpatient setting be-
limited benefits, and no others, for a diagnosis of gender iden-
cause of an underlying medical condition or clinical
tity disorder (gender dysphoria):
status and the Member is under the age of 7 or de-
velopmentally disabled regardless of age or when the 1. Mental Health Services
Member’s health is compromised and for whom
general anesthesia is Medically Necessary regardless Outpatient psychiatric care and Intensive Outpatient
of age. Excludes dental procedures and services of a Care are covered when authorized and provided through
dentist or oral surgeon. the MHSA (see Mental Health and Substance Abuse
Services section). Benefits are limited to a combined
c. Medically Necessary Services in connection with maximum of 60 visits for diagnosis and treatment per
Reconstructive Surgery to correct or repair abnormal Contract year.
structures of the body and which result in more than
a minimal improvement in function or appearance. Member Copayment: $25 per visit
In accordance with the Women’s Health and Cancer 2. Outpatient Prescription Drugs
Rights Act, surgically implanted and other prosthetic
devices (including prosthetic bras) and Reconstruc- Coverage under the Outpatient Prescription Drug bene-
tive Surgery on either breast provided to restore and fit (see Supplement A - Outpatient Prescription Drugs)
achieve symmetry incident to a mastectomy, and is provided for prescription drugs, including self-
treatment of physical complications of a mastectomy, administered injectable medications, that are prescribed
including lymphedemas, are covered. Surgery must in conjunction with a gender identity disorder (gender
be authorized as described herein. Any such Ser- dysphoria), treatment program and obtained from a Par-
vices must be received while the Plan is in force with ticipating Pharmacy. Prior authorization may be re-
respect to the Member. Benefits will be provided in quired for certain medications.
accordance with guidelines established by the Plan
and developed in conjunction with plastic and recon- 3. Transgender Surgical Services
structive surgeons. Hospital and Professional Services are provided for
No benefits will be provided for the following sur- transgender genital surgical services and mastectomies.
geries or procedures unless determined by Blue Benefits will be provided in accordance with guidelines
Shield to be Medically Necessary to correct or repair established by the Plan. These services must be author-
abnormal structures of the body caused by congenital ized by the Member's Personal Physician or the Ac-
defects, developmental abnormalities, trauma, infec- cess+ HMO. Benefits are limited to a $75,000 lifetime
tion, tumors, or disease, and which will result in maximum per Member except for medically necessary
more than minimal improvement in function or ap- services to treat medical complications of these surger-
pearance: ies. Benefits are also provided for necessary travel and
lodging expenses to receive these services only when
(1) Surgery to excise, enlarge, reduce, or change the the Member is referred outside of the Plan Service Area
appearance of any part of the body; by the Plan. These travel and lodging arrangements
must be arranged by or approved in advance by the Plan
(2) Surgery to reform or reshape skin or bone;
and are limited solely to expenses for the Member who
(3) Surgery to excise or reduce skin or connective is undergoing transgender surgery. Approved travel and
tissue that is loose, wrinkled, sagging, or exces- lodging benefits will accrue to the $75,000 lifetime
sive on any part of the body; maximum. See the Summary of Benefits for the appli-
cable copayments for the services provided.
(4) Hair transplantation; and
(5) Upper eyelid blepharoplasty without docu- Exclusions:
mented significant visual impairment or symp- No benefits are provided for:
1. Liposuction to reshape hips, thighs and buttocks;
This limitation shall not apply when breast recon-
struction is performed subsequent to a Medically 2. Cosmetic chest reconstruction or augmentation mam-
Necessary mastectomy, including surgery on either moplasty;
breast to achieve or restore symmetry. 3. Electrolysis and laser hair removal;
4. Drugs for hair loss or growth;
5. Voice therapy or lessons;
6. Sperm or gamete procurement for future infertility or 5. Alveolar ridge surgery of the jaws if performed primarily
storage of sperm, gamete, or embryos. to treat diseases related to the teeth, gums or periodontal
structures or to support natural or prosthetic teeth;
No other services are covered under the Access+ HMO Plan
that are transgender services or are related to the treatment 6. Fluoride treatments except when used with radiation ther-
of gender identity disorder (gender dysphoria), except for apy to the oral cavity.
Medically Necessary treatment of complications arising
See the Principal Limitations, Exceptions, Exclusions and
from any gender identity disorder (gender dysphoria) ser-
Reductions section for additional services that are not cov-
MEDICAL TREATMENT OF TEETH, GUMS, JAW JOINTS OR
MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS
JAW BONES BENEFITS
Blue Shield of California’s MHSA administers and delivers
Hospital and professional Services provided for conditions of
the Plan’s Mental Health and substance abuse Benefits. All
the teeth, gums, or jaw joints and jaw bones, including adja-
Non-Emergency Mental Health and substance abuse Services
cent tissues are a Benefit only to the extent that these Services
must be arranged through the MHSA. Also, all Non-
are provided for:
Emergency Mental Health and substance abuse Services must
1. The treatment of tumors of the gums; be prior authorized by the MHSA. For prior authorization for
Mental Health and substance abuse Services, Members should
2. The treatment of damage to natural teeth caused solely by
contact the MHSA at 1-877-263-9952.
an Accidental Injury is limited to medically necessary
Services until the Services result in initial, palliative sta- All Mental Health and substance abuse Services must be ob-
bilization of the Member as determined by the Plan; tained from MHSA Participating Providers. (See the How to
Use Your Health Plan section, the Mental Health and Sub-
Note: Dental services provided after initial medical stabi-
stance Abuse Services paragraphs for more information.)
lization, prosthodontics, orthodontia and cosmetic ser-
vices are not covered. This Benefit does not include Benefits are provided for the following Medically Necessary
damage to the natural teeth that is not accidental, e.g., re- covered Mental Health and substance abuse Services, subject
sulting from chewing or biting. to applicable Deductible/Copayments and charges in excess of
any Benefit maximums. Coverage for these Services is sub-
3. Medically necessary non-surgical treatment (e.g., splint
ject to all terms, conditions, limitations and exclusions of the
and physical therapy) of Temporomandibular Joint Syn-
Contract, to any conditions or limitations set forth in the bene-
fit description below, and to the Principal Limitations, Excep-
4. Surgical and arthroscopic treatment of TMJ if prior his- tions, Exclusions and Reductions set forth in this booklet.
tory shows conservative medical treatment has failed;
1. Inpatient Services
5. Medically Necessary treatment of maxilla and mandible
Inpatient Hospital and professional Services in connection
(Jaw Joints and Jaw Bones); or
with hospitalization for the treatment of mental illness (includ-
6. Orthognathic Surgery (surgery to reposition the upper ing treatment of Severe Mental Illnesses of a Member of any
and/or lower jaw) which is Medically Necessary to cor- age and of Serious Emotional Disturbances of a Child) are
rect skeletal deformity. covered. All Non-Emergency Mental Health and substance
abuse Services must be prior authorized by the MHSA and
This Benefit does not include:
obtained from MHSA Participating Providers. Residential
1. Services performed on the teeth, gums (other than tu- care is not covered.
mors) and associated periodontal structures, routine care
Note: See Hospital Benefits (Facility Services) in the Plan
of teeth and gums, diagnostic services, preventive or pe-
Benefits section for information on Medically Necessary Inpa-
riodontic services, dental orthoses and prostheses, includ-
tient substance abuse detoxification.
ing hospitalization incident thereto;
(If Inpatient substance abuse treatment is selected as an op-
2. Orthodontia (dental services to correct irregularities or
tional Benefit by your Employer, refer to the Inpatient Sub-
malocclusion of the teeth) for any reason, including
stance Abuse Treatment Supplement for the Benefit descrip-
treatment to alleviate TMJ;
tion, limitations and Deductible/Copayments.)
3. Any procedure (e.g., vestibuloplasty) intended to prepare
2. Outpatient Services
the mouth for dentures or for the more comfortable use of
dentures; a. Medically necessary Outpatient Psychiatric Care for
4. Dental implants (endosteal, subperiosteal or transosteal); other than Severe Mental Illnesses or Serious Emo-
tional Disturbances of a Child, and substance abuse
visits or sessions. This Benefit is limited to a com-
bined visit maximum as shown in the Summary of
Benefits for diagnosis and treatment in any Contract Benefits are provided for orthotic devices for maintaining
Year. Intensive Outpatient Care is not covered under normal Activities of Daily Living only. No benefits are pro-
this Benefit. vided for orthotic devices such as knee braces intended to
provide additional support for recreational or sports activities
b. Medically necessary Outpatient Psychiatric Care for or for orthopedic shoes and other supportive devices for the
the diagnosis and treatment of Severe Mental Ill- feet.
nesses and of Serious Emotional Disturbances of a
Child. Intensive Outpatient Care is covered under Note: See Diabetes Care Benefits in the Plan Benefits section
this Benefit. for devices, equipment, and supplies for the management and
treatment of diabetes.
3. Outpatient Partial Hospitalization and Outpatient ECT
Services OUTPATIENT X-RAY, PATHOLOGY AND LABORATORY
Hospital and professional Services in connection with psychi-
atric Partial Hospitalization and ECT for the treatment of 1. Laboratory, X-ray, Major Diagnostic Services. All Out-
mental illness (including treatment of Severe Mental Illnesses patient diagnostic X-ray and clinical laboratory tests and
of a Member of any age and of Serious Emotional Distur- Services, including diagnostic imaging, electrocardio-
bances of a Child) are covered. grams, and diagnostic clinical isotope Services.
4. Psychological Testing 2. Genetic Testing and Diagnostic Procedures. Genetic
testing for certain conditions when the Member has risk
Psychological testing is a covered Benefit when the Member
factors such as family history or specific symptoms. The
is referred by an MHSA Provider and the procedure is prior
testing must be expected to lead to increased or altered
authorized by the MHSA.
monitoring for early detection of disease, a treatment plan
5. Psychosocial Support through LifeReferrals 24/7 or other therapeutic intervention and determined to be
Medically Necessary and appropriate in accordance with
See the Mental Health and Substance Abuse Services para-
Blue Shield of California medical policy.
graphs under the How to Use Your Health Plan section for
information on psychosocial support services. Note: See Pregnancy and Maternity Care Benefits in the Plan
Benefits section for genetic testing for prenatal diagnosis of
ORTHOTICS BENEFITS genetic disorders of the fetus.
Medically necessary Orthoses for Activities of Daily Living
PKU RELATED FORMULAS AND SPECIAL FOOD
are covered, including the following:
1. Special footwear required for foot disfigurement which
Benefits are provided for enteral formulas, related medical
includes, but is not limited to, foot disfigurement from
supplies, and Special Food Products that are Medically Nec-
cerebral palsy, arthritis, polio, spina bifida, or by accident
essary for the treatment of phenylketonuria (PKU) to avert the
or developmental disability;
development of serious physical or mental disabilities or to
2. Medically Necessary functional foot Orthoses that are promote normal development or function as a consequence of
custom made rigid inserts for shoes, ordered by a Physi- PKU. These Benefits must be prior authorized and must be
cian or podiatrist, and used to treat mechanical problems prescribed or ordered by the appropriate health care profes-
of the foot, ankle or leg by preventing abnormal motion sional.
and positioning when improvement has not occurred with
a trial of strapping or an over-the-counter stabilizing de- PREGNANCY AND MATERNITY CARE BENEFITS
vice; The following pregnancy and maternity care is covered sub-
3. Medically necessary knee braces for post-operative Re- ject to the exclusions listed in the Principal Limitations, Ex-
habilitation following ligament surgery, instability due to ceptions, Exclusions and Reductions section:
injury, and to reduce pain and instability for patients with 1. Prenatal and postnatal Physician office visits and deliv-
osteoarthritis. ery, including prenatal diagnosis of genetic disorders of
Benefits for Medically Necessary Orthoses are provided at the the fetus by means of diagnostic procedures in cases of
most cost effective level of care that is consistent with profes- high-risk pregnancy.
sionally recognized standards of practice. If there are 2 or Note: See Outpatient X-ray, Pathology and Laboratory Bene-
more professionally recognized appliances equally appropri- fits in the Plan Benefits section for information on coverage of
ate for a condition, this Plan will provide Benefits based on other genetic testing and diagnostic procedures.
the most cost effective appliance. Routine maintenance is not
covered. No Benefits are provided for backup or alternate 2. Inpatient Hospital Services. Hospital Services for the
items. purposes of a normal delivery, routine newborn circumci-
sion,* Cesarean section, complications or medical condi-
tions arising from pregnancy or resulting childbirth.
3. Outpatient routine newborn circumcision.* ministration (oral, injection or otherwise) solely for the
purpose of travel.
*For the purposes of this Benefit, routine newborn cir-
cumcisions are circumcisions performed within 31 days 3. Hearing screening by the Personal Physician for Mem-
of birth unrelated to illness or injury. Routine circumci- bers through the age of 18 to determine the need for an
sions after this time period are covered for sick babies audiogram or for hearing correction, as well as newborn
when authorized. hearing screening Services.
Note: The Newborns’ and Mothers’ Health Protection Act 4. Vision screening by the Personal Physician for Members
requires group health plans to provide a minimum Hospital through the age of 18 to determine the need for a refrac-
stay for the mother and newborn child of 48 hours after a tion for vision correction.
normal, vaginal delivery and 96 hours after a C-section unless
5. Colorectal cancer screening for Members age 50 and
the attending Physician, in consultation with the mother, de-
older. Benefits are provided based on Blue Shield’s Pre-
termines a shorter Hospital length of stay is adequate.
ventive Health Guidelines. These guidelines regarding
If the Hospital stay is less than 48 hours after a normal, vagi- examinations and tests are derived from the most recent
nal delivery or less than 96 hours after a C-section, a follow- version with all updates of the Guide to Preventive Ser-
up visit for the mother and newborn within 48 hours of dis- vices of the U.S. Preventive Services Task Force as
charge is covered when prescribed by the treating Physician. convened by the U.S. Public Health Service and those of
This visit shall be provided by a licensed health care provider the American Cancer Society, including frequency and pa-
whose scope of practice includes postpartum and newborn tient age recommendations.
care. The treating Physician, in consultation with the mother,
6. Osteoporosis screening benefits are provided for Mem-
shall determine whether this visit shall occur at home, the con-
bers age 65 and older or 60 and older if at increased risk.
tracted facility, or the Physician’s office.
7. Health education and health promotion Services provided
PREVENTIVE HEALTH BENEFITS by Blue Shield’s Center for Health Improvement offer a
Preventive Care Services are those primary preventive medi- variety of wellness resources including, but not limited to,
cal Services provided by a Physician for the early detection of a Member newsletter and a prenatal health education pro-
disease when no symptoms are present and for those items gram.
specifically listed below. 8. Blue Shield’s Internet site is located at
1. Scheduled routine physical examinations as follows: http://www.blueshieldca.com. Members with Internet ac-
cess and a Web browser may view and download health-
a. Well-baby care through age 2 years; care information.
b. Exams every year, age 3-19 years; Note: See Family Planning and Infertility Benefits, Outpatient
X-ray, Pathology and Laboratory Benefits, Pregnancy and
c. Exams every 5 years, age 20-40 years; Maternity Care Benefits, and Professional (Physician) Bene-
d. Exams every 2 years, age 41-50 years; fits in the Plan Benefits section for information on other pre-
ventive health and diagnostic screening services, including
e. Exams every year over age 50 years; genetic testing and diagnostic procedures, family planning,
and prenatal care.
f. Routine breast and pelvic exams and Pap tests or
other FDA (Food and Drug Administration) ap- PROFESSIONAL (PHYSICIAN) BENEFITS
proved cervical cancer and human papillomavirus vi- (OTHER THAN FOR MENTAL HEALTH AND SUBSTANCE
rus (HPV) screening tests every year. A woman may ABUSE SERVICES)
self-refer to an OB/GYN or family practice Physi-
1. Physician Office Visits. Office visits for examination,
cian who is in the same Medical Group/IPA as her
diagnosis, and treatment of a medical condition, disease
Personal Physician for a routine annual gynecologi-
or injury, including Specialist office visits, second opin-
ion or other consultations, office surgery, Outpatient
g. Mammography for screening purposes recom- chemotherapy and radiation therapy, diabetic counseling,
mended by Member’s Personal Physician. audiometry examinations when performed by a Physician
or by an audiologist at the request of a Physician, and
2. Pediatric and adult immunizations and the immunizing OB/GYN Services from an obstetrician/gynecologist or
agent, as recommended by the American Academy of Pe- family practice Physician who is within the same Medical
diatrics and the United States Public Health Service Group/IPA as the Personal Physician. Benefits are also
through its U. S. Preventive Services Task Force and/or provided for asthma self-management training and educa-
the Advisory Committee on Immunization Practices tion to enable a Member to properly use asthma-related
(ACIP) of the Centers for Disease Control (CDC), except medication and equipment such as inhalers, spacers,
for immunizations and vaccinations by any mode of ad- nebulizers and peak flow monitors.
2. Home Visits. Medically Necessary home visits by Plan • Surgery to excise, enlarge, reduce, or change the ap-
Physician. pearance of any part of the body;
3. Inpatient Medical and Surgical Physician Services. Phy- • Surgery to reform or reshape skin or bone;
sicians’ Services in a Hospital or Skilled Nursing Facility
for examination, diagnosis, treatment and consultation in- • Surgery to excise or reduce skin or connective tissue
cluding the Services of a surgeon, assistant surgeon, anes- that is loose, wrinkled, sagging, or excessive on any
thesiologist, pathologist and radiologist. Inpatient profes- part of the body;
sional Services are covered only when Hospital and
Skilled Nursing Facility Services are also covered. • Hair transplantation; and
4. Internet Based Consultation. Medically Necessary con- • Upper eyelid blepharoplasty without documented
sultations with Internet Ready Physicians via the Blue significant visual impairment or symptomatology.
Shield approved Internet portal. Internet based consulta-
This limitation shall not apply when breast reconstruction
tions are available only to Members whose Personal Phy-
is performed subsequent to a Medically Necessary mas-
sicians (or other Physicians to whom you have been re-
tectomy, including surgery on either breast to achieve or
ferred for care within your Personal Physician’s Medical
Group/IPA) have agreed to provide Internet based con-
sultations via the Blue Shield approved Internet portal PROSTHETIC APPLIANCES BENEFITS
(“Internet Ready”). Internet based consultations for Men-
tal Health and substance abuse care are not covered. Re- Medically Necessary Prostheses for Activities of Daily Living
fer to the On-Line Physician Directory to determine are covered. Benefits are provided at the most cost-effective
whether your Physician is Internet Ready and how to ini- level of care that is consistent with professionally recognized
tiate an Internet based consultation. This information can standards of practice. If there are 2 or more professionally
be accessed at http://www.blueshieldca.com. recognized items equally appropriate for a condition, Benefits
will be based on the most cost-effective item.
5. Injectable medications approved by the Food and Drug
Administration (FDA) are covered for the Medically Medically Necessary Prostheses for Activities of Daily Living
Necessary treatment of medical conditions when pre- are covered, including the following:
scribed or authorized by the Personal Physician or as de- 1. Blom-Singer and artificial larynx Prostheses for speech
scribed herein. Insulin and Home Self-Administered In- following a laryngectomy;
jectables will be covered if the Member’s Employer pro-
vides supplemental Benefits for prescription drugs 2. Artificial limbs and eyes;
through the supplemental Benefit for Outpatient Prescrip- 3. Supplies necessary for the operation of Prostheses;
4. Initial fitting and replacement after the expected life of
6. Medically Necessary Services in connection with Recon- the item;
structive Surgery to correct or repair abnormal structures
of the body and which result in more than a minimal im- 5. Repairs, even if due to damage.
provement in function or appearance. In accordance with Routine maintenance is not covered. Benefits do not include
the Women’s Health and Cancer Rights Act, surgically wigs for any reason or any type of speech or language assis-
implanted and other prosthetic devices (including pros- tance devices except as specifically provided above. See the
thetic bras) and Reconstructive Surgery on either breast Principal Limitations, Exceptions, Exclusions and Reductions
provided to restore and achieve symmetry incident to a section for a listing of excluded speech and language assis-
mastectomy, and treatment of physical complications of a tance devices. No benefits are provided for backup or alter-
mastectomy, including lymphedemas, are covered. Sur- nate items.
gery must be authorized as described herein. Any such
Services must be received while the Plan is in force with Benefits are provided for contact lenses, if Medically Neces-
respect to the Member. Benefits will be provided in ac- sary to treat eye conditions such as keratoconus, keratitis sicca
cordance with guidelines established by the Plan and de- or aphakia following cataract surgery when no intraocular lens
veloped in conjunction with plastic and reconstructive has been implanted. Note: These contact lenses will not be
surgeons. covered under your Blue Shield Access+ HMO health Plan if
your Employer provides supplemental Benefits for vision care
No benefits will be provided for the following surgeries that cover contact lenses through a MESVision Plan pur-
or procedures unless determined by Blue Shield to be chased through Blue Shield of California. There is no coordi-
Medically Necessary to correct or repair abnormal struc- nation of benefits between the health Plan and the vision plan
tures of the body caused by congenital defects, develop- for these Benefits.
mental abnormalities, trauma, infection, tumors, or dis-
ease, and which will result in more than minimal im- Note: For surgically implanted and other prosthetic devices
provement in function or appearance: (including prosthetic bras) provided to restore and achieve
symmetry incident to a mastectomy, see Ambulatory Surgery cally Necessary, pursuant to the treatment plan, and likely to
Center Benefits, Hospital Benefits (Facility Services), and result in clinically significant progress as measured by objec-
Professional (Physician) Benefits in the Plan Benefits section. tive and standardized tests. The Provider’s treatment plan and
Blom-Singer and artificial larynx Prostheses for speech fol- records will be reviewed periodically. When continued treat-
lowing a laryngectomy are covered as a surgical professional ment is not Medically Necessary pursuant to the treatment
Benefit. plan, not likely to result in additional clinically significant
improvement, or no longer requires skilled services of a li-
REHABILITATION (PHYSICAL, OCCUPATIONAL AND censed speech therapist, the Member will be notified of this
RESPIRATORY THERAPY) BENEFITS determination and benefits will not be provided for services
Rehabilitation Services include Physical Therapy, Occupa- rendered after the date of written notification.
tional Therapy, and/or Respiratory Therapy pursuant to a writ- Except as specified above and as stated under Home Health
ten treatment plan for as long as continued treatment is Medi- Care Benefits, no Outpatient Benefits are provided for Speech
cally Necessary, and when rendered in the Provider’s office or Therapy, speech correction, or speech pathology services.
Outpatient department of a Hospital. Benefits for Speech
Therapy are described in Speech Therapy Benefits in the Plan Note: See Home Health Care Benefits in the Plan Benefits
Benefits section. Medically Necessary Services will be au- section for information on coverage for Speech Therapy Ser-
thorized for an initial treatment period and any additional sub- vices rendered in the home, including visit limits. See Hospi-
sequent Medically Necessary treatment periods if after con- tal Benefits (Facility Services) in the Plan Benefits section for
ducting a review of the initial and each additional subsequent information on Inpatient Benefits and Hospice Program Bene-
period of care, it is determined that continued treatment is fits in the Plan Benefits section for hospice program Services.
Medically Necessary and is provided with the expectation that
the patient has restorative potential.
Organ Transplant Benefits
Note: See Home Health Care Benefits in the Plan Benefits
section for information on coverage for Rehabilitation Ser- Hospital and professional Services provided in connection
vices rendered in the home, including visit limits. with human organ transplants are a Benefit to the extent that
SKILLED NURSING FACILITY BENEFITS
1. Provided in connection with the transplant of a cornea,
Subject to all of the Inpatient Hospital Services provisions, kidney, or skin, when the recipient of such transplant is a
Medically Necessary skilled nursing Services, including Member;
Subacute Care, will be covered when provided in a Skilled
Nursing Facility and authorized. This Benefit is limited to a 2. Services incident to obtaining the human organ transplant
combined day maximum as shown in the Summary of Benefits material from a living donor or an organ transplant bank.
during any Contract Year except when received through a Special Transplant Benefits
Hospice Program provided by a Participating Hospice
Agency. This day maximum is a combined Benefit maximum Blue Shield will provide Benefits for certain procedures, listed
for all skilled nursing Services whether in a Hospital or a below, only if (1) performed at a Special Transplant Facility
Skilled Nursing Facility. Custodial care is not covered. contracting with Blue Shield of California to provide the pro-
cedure, (2) prior authorization is obtained, in writing, from
Note: For information concerning hospice program Benefits Blue Shield's Medical Director and (3) the recipient of the
see Hospice Program Benefits in the Plan Benefits section. transplant is a Subscriber or Dependent. The following condi-
SPEECH THERAPY BENEFITS tions are applicable:
Initial Outpatient Benefits for Speech Therapy Services when 1. Blue Shield reserves the right to review all requests for
diagnosed and ordered by a Physician and provided by an prior authorization for these Special Transplant Benefits,
appropriately licensed speech therapist, pursuant to a written and to make a decision regarding Benefits based on (a)
treatment plan for an appropriate time to: (1) correct or im- the medical circumstances of each patient and (b) consis-
prove the speech abnormality, or (2) evaluate the effectiveness tency between the treatment proposed and Blue Shield
of treatment, and when rendered in the Provider’s office or medical policy. Failure to obtain prior written authoriza-
Outpatient department of a Hospital. tion as described above and/or failure to have the proce-
dure performed at a contracting Special Transplant Facil-
Services are provided for the correction of, or clinically sig- ity will result in denial of claims for this Benefit.
nificant improvement of, speech abnormalities that are the
likely result of a diagnosed and identifiable medical condition, 2. The following procedures are eligible for coverage under
illness, or injury to the nervous system or to the vocal, swal- this provision:
lowing, or auditory organs. a. Human heart transplants;
Continued Outpatient Benefits will be provided for Medically
b. Human lung transplants;
Necessary Services as long as continued treatment is Medi-
c. Human heart and lung transplants in combination; Urgent Services. See Claims for Emergency and Out-of-Area
Urgent Services in the How to Use Your Health Plan section
d. Human kidney and pancreas transplants in combina- for additional information. Note: Authorization by Blue
tion; Shield is required for care that involves a surgical or other
e. Human liver transplants; procedure or inpatient stay.
Note: Up to two Medically Necessary Out-of-Area Follow-up
f. Human bone marrow transplants, including autolo-
Care outpatient visits are covered. Authorization by Blue
gous bone marrow transplantation (ABMT) or
Shield is required for more than two follow-up outpatient vis-
autologous peripheral stem cell transplantation used
its. Blue Shield may direct the member to receive the addi-
to support high-dose chemotherapy when such
tional follow-up care from the Personal Physician.
treatment is Medically Necessary and is not Experi-
mental or Investigational; Outside the United States, Urgent Services are available
through the BlueCard Worldwide Network, but may be re-
g. Pediatric human small bowel transplants; ceived from any provider.
h. Pediatric and adult human small bowel and liver Members before traveling abroad should call their local
transplants in combination. Member Services office for the most current listing of partici-
3. Services incident to obtaining the transplant material pating providers worldwide or they can go on line at
from a living donor or an organ transplant bank will be http://www.bcbs.com and select the “Find a Doctor or Hospital”
covered. tab. However, a Member is not required to receive Urgent
Services outside of the United States from the BlueCard
URGENT SERVICES BENEFITS Worldwide Network. If the Member does not use the Blue-
Card Worldwide Network, a claim must be submitted as de-
Urgent Services required when the Member is within his or scribed in Claims for Emergency and Out-of-Area Urgent
her Personal Physician Service Area must be obtained in ac- Services in the How to Use Your Health Plan section.
cordance with the How to Use Your Health Plan section.
When outside the Plan Service Area, Members may receive PRINCIPAL LIMITATIONS, EXCEPTIONS,
care for Urgent Services as follows:
EXCLUSIONS AND REDUCTIONS
For Urgent Services within California but outside the Mem- GENERAL EXCLUSIONS AND LIMITATIONS
ber’s Personal Physician Service Area, the Member should, if
Unless exceptions to the following exclusions are
possible, contact Blue Shield Member Services at the number
provided on the last page of this booklet in accordance with specifically made elsewhere in the Contract, no
the How to Use Your Health Plan section. Member Services Benefits are provided for services which are:
will assist Members in receiving Urgent Services through a
Blue Shield of California Plan Provider. Members may also
1. Experimental or Investigational in Nature ex-
locate a Plan Provider by visiting Blue Shield’s internet site at cept for Services for Members who have been
http://www.blueshieldca.com. You are not required to use a accepted into an approved clinical trial for can-
Blue Shield of California Plan Provider to receive Urgent cer as provided under Clinical Trial for Cancer
Services; you may use any provider. However, the services Benefits in the Plan Benefits section;
will be reviewed retrospectively by the Plan to determine
whether the services were Urgent Services. Note: Authoriza- 2. for or incident to services rendered in the home
tion by Blue Shield is required for care that involves a surgical or hospitalization or confinement in a health fa-
or other procedure or inpatient stay.
cility primarily for Custodial, Maintenance,
Outside California or the United States Domiciliary Care, or Residential Care except as
When temporarily traveling outside California or the United provided under Hospice Program Benefits in
States, if possible, call the 24-hour toll-free number 1-800-810 the Plan Benefits section; or rest;
BLUE (2583) to obtain information about the nearest Blue-
Card Program participating provider. When a BlueCard Pro- 3. for substance abuse treatment or rehabilitation
gram participating provider is available, you should obtain on an Inpatient, Partial Hospitalization or Out-
out-of-area urgent or follow-up care from a participating pro- patient basis, except as specifically provided
vider whenever possible, but you may also receive care from a
under Mental Health and Substance Abuse
non-BlueCard participating provider. If you received services
from a non-Blue Shield provider, you must submit a claim to Benefits in the Plan Benefits section;
Blue Shield for payment. The services will be reviewed retro-
spectively by the Plan to determine whether the services were
4. performed in a Hospital by Hospital officers, tory, and radiology services, services or medi-
residents, interns and others in training; cations to treat low sperm count, or services in-
cident to or resulting from procedures for a sur-
5. for or incident to hospitalization or confinement
rogate mother who is otherwise not eligible for
in a pain management center to treat or cure
covered Pregnancy and Maternity Care Benefits
chronic pain, except as may be provided
under a Blue Shield of California health plan;
through a Participating Hospice Agency and
except as Medically Necessary; 11. for or incident to the treatment of Infertility or
any form of assisted reproductive technology,
6. for Cosmetic Surgery or any resulting compli-
including but not limited to the reversal of a va-
cations, except that Medically Necessary Ser-
sectomy or tubal ligation, or any resulting com-
vices to treat complications of Cosmetic Sur-
plications, except for medically necessary
gery (e.g., infections or hemorrhages) will be a
treatment of medical complications;
Benefit, but only upon review and approval by
a Blue Shield Physician consultant. Without 12. for or incident to Speech Therapy, speech cor-
limiting the foregoing, no benefits will be pro- rection, or speech pathology or speech abnor-
vided for the following surgeries or procedures: malities that are not likely the result of a diag-
nosed, identifiable medical condition, injury or
• Lower eyelid blepharoplasty;
illness except as specifically provided under
• Spider veins; Home Health Care Benefits, Speech Therapy
• Services and procedures to smooth the skin Benefits, and Hospice Program Benefits in the
(e.g., chemical face peels, laser resurfacing, Plan Benefits section;
and abrasive procedures); 13. for routine foot care including callus, corn par-
• Hair removal by electrolysis or other ing or excision and toenail trimming (except as
means; and may be provided through a Participating Hos-
pice Agency); treatment (other than surgery) of
• Reimplantation of breast implants origi- chronic conditions of the foot, including but not
nally provided for cosmetic augmentation; limited to weak or fallen arches, flat or pro-
7. incident to an organ transplant; except as pro- nated foot, pain or cramp of the foot, bunions,
vided under Transplant Benefits in the Plan muscle trauma due to exertion or any type of
Benefits section; massage procedure on the foot; for special
footwear (e.g., non-custom made or over-the-
8. for convenience items such as telephones, TVs,
counter shoe inserts or arch supports) except as
guest trays, and personal hygiene items;
specifically provided under Orthotics Benefits
9. for transgender or gender dysphoria conditions, and Diabetes Care Benefits in the Plan Benefits
including but not limited to intersex surgery section;
(transsexual operations), except as specifically
14. for eye refractions, surgery to correct refractive
provided under the Limited Transgender Bene-
error (such as but not limited to radial keratot-
fit, or any related services, or any resulting
omy, refractive keratoplasty), lenses and frames
medical complications, except for treatment of
for eye glasses, contact lenses (except as pro-
medical complications that is Medically Neces-
vided under Prosthetic Appliances Benefits in
the Plan Benefits section, and video-assisted
10. for any services related to assisted reproductive visual aids or video magnification equipment
technology, including but not limited to the for any purpose);
harvesting or stimulation of the human ovum,
15. for hearing aids, except as specifically provided
in vitro fertilization, Gamete Intrafallopian
under Hearing Aid Services in the Plan Benefits
Transfer (G.I.F.T.) procedure, artificial insemi-
nation, including related medications, labora-
16. for Dental Care or services incident to the lien upon such other benefits up to the reason-
treatment, prevention, or relief of pain or dys- able cash value of Benefits provided by Blue
function of the Temporomandibular Joint Shield for the treatment of the injury or disease
and/or muscles of mastication, except as spe- as reflected by the providers’ usual billed
cifically provided under Medical Treatment of charges;
Teeth, Gums, Jaw Joints or Jaw Bones Benefits 23. in connection with private duty nursing, except
in the Plan Benefits section; as provided under Hospital Benefits (Facility
17. for or incident to services and supplies for Services), Home Health Care Benefits, Home
treatment of the teeth and gums (except for tu- Infusion/Home Injectable Therapy Benefits, and
mors) and associated periodontal structures, in- Hospice Program Benefits in the Plan Benefits
cluding but not limited to diagnostic, preven- section;
tive, orthodontic and other services such as
24. for testing for intelligence or learning disabili-
dental cleaning, tooth whitening, X-rays, topi-
cal fluoride treatment except when used with
radiation therapy to the oral cavity, fillings, and 25. for rehabilitation services except as specifically
root canal treatment; treatment of periodontal provided under Hospital Benefits (Facility Ser-
disease or periodontal surgery for inflammatory vices), Home Health Care Benefits, and Reha-
conditions; tooth extraction; dental implants; bilitation Benefits in the Plan Benefits section;
braces, crowns, dental orthoses and prostheses; 26. for prescribed drugs and medicines for Outpa-
except as specifically provided under Hospital tient care except as provided through a Partici-
Benefits (Facility Services) and Medical Treat- pating Hospice Agency when the Member is
ment of Teeth, Gums, Jaw Joints or Jaw Bones receiving Hospice Services and except as may
Benefits in the Plan Benefits section; be provided under the Outpatient Prescription
18. for or incident to reading, vocational, educa- Drugs Supplement or Home Infusion/Home In-
tional, recreational, art, dance or music therapy; jectable Therapy Benefits in the Plan Benefits
weight control or exercise programs; nutritional section;
counseling except as specifically provided for 27. for contraceptives and contraceptive devices,
under Diabetes Care Benefits in the Plan Bene- except as specifically included under Family
fits section; Planning and Infertility Benefits in the Plan
19. for learning disabilities, behavioral problems or Benefits section and under the Outpatient Pre-
social skills training/therapy; scription Drugs Supplement; oral contracep-
tives and diaphragms are excluded, except as
20. for or incident to acupuncture, except as spe-
may be provided under the Outpatient Prescrip-
tion Drugs Supplement; no benefits are pro-
21. for spinal manipulation and adjustment, except vided for contraceptive implants;
as specifically provided under Professional
28. for transportation services other than provided
(Physician) Benefits (other than for Mental
under Ambulance Benefits in the Plan Benefits
Health and Substance Abuse Benefits) in the
Plan Benefits section;
29. for unauthorized non-Emergency Services;
22. for or incident to any injury or disease arising
out of, or in the course of, any employment for 30. not provided by, prescribed, referred, or author-
salary, wage or profit if such injury or disease is ized as described herein except for Access+
covered by any workers’ compensation law, Specialist visits, OB/GYN Services provided
occupational disease law or similar legislation. by an obstetrician/gynecologist or family prac-
However, if Blue Shield provides payment for tice Physician within the same Medical
such services it will be entitled to establish a Group/IPA as the Personal Physician, Emer-
gency Services or Urgent Services as provided 37. for non-prescription (over-the-counter) medical
under Emergency Room Benefits and Urgent equipment or supplies that can be purchased
Services Benefits in the Plan Benefits section, without a licensed provider’s prescription or-
when specific authorization has been obtained der, even if a licensed provider writes a pre-
in writing for such Services as described herein, scription order for a non-prescription item, ex-
for Mental Health and substance abuse Services cept as specifically provided under Home
which must be arranged through the MHSA or Health Care Benefits, Home Infusion/Home In-
for Hospice Services received by a Participating jectable Therapy Benefits, Hospice Program
Hospice Agency; Benefits, and Diabetes Care Benefits in the
Plan Benefits section;
31. performed by a Close Relative or by a person
who ordinarily resides in the Subscriber’s or 38. for Reconstructive Surgery and procedures:
Dependent’s home; 1) where there is another more appropriate sur-
gical procedure that is approved by a Blue
32. for orthopedic shoes, except as provided under
Shield Physician consultant, or 2) when the
Diabetes Care Benefits in the Plan Benefits sec-
surgery or procedure offers only a minimal im-
tion, home testing devices, environmental con-
provement in function or in the appearance of
trol equipment, generators, exercise equipment,
the enrollees, e.g., spider veins, or 3) as limited
self help/educational devices, or for any type of
under Ambulatory Surgery Center Benefits,
communicator, voice enhancer, voice prosthe-
Hospital Benefits (Facility Services), and Pro-
sis, electronic voice producing machine, or any
fessional (Physician) Benefits in the Plan Bene-
other language assistance devices, except as
provided under Prosthetic Appliances Benefits in
the Plan Benefits section, vitamins, and comfort 39. for drugs and medicines which cannot be law-
items; fully marketed without approval of the U.S.
Food and Drug Administration (the FDA);
33. for physical exams required for licensure, em-
however, drugs and medicines which have re-
ployment, or insurance unless the examination
ceived FDA approval for marketing for one or
corresponds to the schedule of routine physical
more uses will not be denied on the basis that
examinations provided under Preventive Health
they are being prescribed for an off-label use if
Benefits in the Plan Benefits section, or for
the conditions set forth in California Health and
immunizations and vaccinations by any mode
Safety Code, Section 1367.21 have been met;
of administration (oral, injection or otherwise)
solely for the purpose of travel; 40. for prescription or non-prescription food and
nutritional supplements, except as under PKU
34. for penile implant devices and surgery, and any
Related Formulas and Special Food Products
related services except for any resulting com-
Benefits and Home Infusion/Home Injectable
plications and Medically Necessary Services as
Therapy Benefits in the Plan Benefits section,
provided under Ambulatory Surgery Center
and except as provided through a hospice
Benefits, Hospital Benefits (Facility Services),
and Professional (Physician) Benefits in the
Plan Benefits section; 41. for genetic testing except as described under
Outpatient X-ray, Pathology and Laboratory
35. for home testing devices and monitoring
Benefits and Pregnancy and Maternity Care
equipment except as specifically provided in
Benefits in the Plan Benefits section;
Durable Medical Equipment Benefits in the
Plan Benefits section; 42. for services provided by an individual or entity
that is not licensed or certified by the state to
36. for or incident to sexual dysfunctions and sex-
provide health care services, or is not operating
ual inadequacies, except as provided for treat-
within the scope of such license or certification,
ment of organically based conditions;
except as specifically stated herein;
43. not specifically listed as a benefit. group that employs less than 100 employees
(as defined by Medicare Secondary Payer
See the Grievance Process section for information
on filing a grievance, your right to seek assistance
from the Department of Managed Health Care, and c. When you are eligible for Medicare solely
your rights to independent medical review. due to end-stage renal disease after the first
30 months that you are eligible to receive
MEDICAL NECESSITY EXCLUSION benefits for end-stage renal disease from
All Services must be Medically Necessary. The Medicare.
fact that a Physician or other provider may pre- d. When you are retired and age 65 years or
scribe, order, recommend, or approve a service or older.
supply does not, in itself, make it Medically Neces-
sary, even though it is not specifically listed as an When your Blue Shield group plan provides bene-
exclusion or limitation. Blue Shield may limit or fits after Medicare, the combined benefits from
exclude Benefits for services which are not Medi- Medicare and your Blue Shield group plan will
cally Necessary. equal, but not exceed, what Blue Shield would
have paid if you were not eligible to receive bene-
LIMITATIONS FOR DUPLICATE COVERAGE fits from Medicare (based on the lower of Blue
Shield’s Allowed Charges or the Medicare allowed
When you are eligible for Medicare
amount). Your Blue Shield group plan Deductible
1. Your Blue Shield group plan will provide bene- and Copayments will be waived.
fits before Medicare in the following situations:
When you are eligible for Medi-Cal
a. When you are eligible for Medicare due to
Medi-Cal always provides benefits last.
age, if the Subscriber is actively working
for a group that employs 20 or more em- When you are a qualified veteran
ployees (as defined by Medicare Secondary If you are a qualified veteran your Blue Shield
Payer laws). group plan will pay the reasonable value or Blue
b. When you are eligible for Medicare due to Shield’s Allowed Charges for covered Services
disability, if the Subscriber is covered by a provided to you at a Veteran’s Administration facil-
group that employs 100 or more employees ity for a condition that is not related to military ser-
(as defined by Medicare Secondary Payer vice. If you are a qualified veteran who is not on
laws). active duty, your Blue Shield group plan will pay
the reasonable value or Blue Shield’s Allowed
c. When you are eligible for Medicare solely
Charges for covered Services provided to you at a
due to end-stage renal disease during the
Department of Defense facility, even if provided
first 30 months that you are eligible to re-
for conditions related to military service.
ceive benefits for end-stage renal disease
from Medicare. When you are covered by another government
2. Your Blue Shield group plan will provide bene-
fits after Medicare in the following situations: If you are also entitled to benefits under any other
federal or state governmental agency, or by any
a. When you are eligible for Medicare due to
municipality, county or other political subdivision,
age, if the Subscriber is actively working
the combined benefits from that coverage and your
for a group that employs less than 20 em-
Blue Shield group plan will equal, but not exceed,
ployees (as defined by Medicare Secondary
what Blue Shield would have paid if you were not
eligible to receive benefits under that coverage
b. When you are eligible for Medicare due to (based on the reasonable value or Blue Shield’s
disability, if the Subscriber is covered by a Allowed Charges).
Contact the Member Services department at the provided, calculated in accordance with Cali-
telephone number shown at the end of this docu- fornia Civil Code Section 3040. The lien may
ment if you have any questions about how Blue be filed with the third party, the third party’s
Shield coordinates your group plan benefits in the agent or attorney, or the court, unless otherwise
above situations. prohibited by law.
EXCEPTION FOR OTHER COVERAGE A Member’s failure to comply with 1. through 3.
above shall not in any way act as a waiver, release,
A Plan Provider may seek reimbursement from or relinquishment of the rights of Blue Shield, the
other third party payers for the balance of its rea- Member’s designated Medical Group, or IPA.
sonable charges for Services rendered under this
Plan. Further, if the Member receives services from a
Plan Hospital for such injuries, the Hospital has the
CLAIMS AND SERVICES REVIEW right to collect from the Member the difference be-
Blue Shield reserves the right to review all claims tween the amount paid by Blue Shield and the
and services to determine if any exclusions or other Hospital’s reasonable and necessary charges for
limitations apply. Blue Shield may use the services such services when payment or reimbursement is
of Physician consultants, peer review committees received by the Member for medical expenses. The
of professional societies or Hospitals, and other Plan Hospital’s right to collect shall be in accor-
consultants to evaluate claims. dance with California Civil Code Section 3045.1.
REDUCTIONS - THIRD PARTY LIABILITY COORDINATION OF BENEFITS
Coordination of Benefits is designed to provide maximum
If a Member is injured through the act or omission coverage for medical and Hospital Services at the lowest cost
of another person (a “third party”), Blue Shield, the by avoiding excessive payments.
Member’s designated Medical Group, and the IPA When a person who is covered under this group Plan is also
shall, with respect to Services required as a result covered under another group plan, or selected group, or blanket
of that injury, provide the Benefits of the Plan and disability insurance contract, or any other contractual arrange-
have an equitable right to restitution or other avail- ment or any portion of any such arrangement whereby the
able remedy to recover the reasonable costs of Ser- members of a group are entitled to payment of, or reimburse-
ment for, Hospital or medical expenses, such person will not be
vices provided to the Member. permitted to make a “profit” on a disability by collecting bene-
The Member is required to: fits in excess of actual value or cost during any Calendar Year.
Instead, payments will be coordinated between the plans in
1. Notify Blue Shield in writing of any actual or order to provide for “allowable expenses” (these are the ex-
potential claim or legal action which such penses that are incurred for services and supplies covered
Member anticipates bringing or has brought under at least one of the plans involved) up to the maximum
against the third party arising from the alleged benefit value or amount payable by each plan separately.
acts or omissions causing the injury or illness, If the covered person is also entitled to benefits under any of
not later than 30 days after submitting or filing the conditions as outlined under the “Limitations for Duplicate
a claim or legal action against the third party; Coverage” provision, benefits received under any such condi-
and tion will not be coordinated with the Benefits of this Plan.
The following rules determine the order of benefit payments:
2. Agree to fully cooperate with Blue Shield and
the Member’s designated Medical Group, and When the other plan does not have a coordination of benefits
provision, it will always provide its benefits first. Otherwise,
IPA to execute any forms or documents needed the plan covering the patient as an employee will provide its
to assist them in exercising their equitable right benefits before the plan covering the patient as a Dependent.
to restitution or other available remedies; and
Except for cases of claims for a Dependent child whose par-
3. Provide Blue Shield and the Member’s desig- ents are separated or divorced, the plan which covers the pa-
nated Medical Group, and IPA with a lien, in tient as a Dependent of a person whose date of birth, (exclud-
ing year of birth), occurs earlier in a Calendar Year, shall de-
the amount of the reasonable costs of Benefits
termine its benefits before a plan which covers that person as a If payments which should have been made under this Plan in
Dependent of a person whose date of birth, (excluding year of accordance with these provisions have been made by another
birth), occurs later in a Calendar Year. If either plan does not plan, Blue Shield may pay to the other plan the amount neces-
have the provisions of this paragraph regarding Dependents, sary to satisfy the intent of these provisions. This amount
which results either in each plan determining its benefits be- shall be considered as Benefits paid under this Plan. Blue
fore the other or in each plan determining its benefits after the Shield shall be fully discharged from liability under this Plan
other, the provisions of this paragraph shall not apply, and the to the extent of these payments.
rule set forth in the plan which does not have the provisions of
If payments have been made by Blue Shield in excess of the
this paragraph shall determine the order of benefits.
maximum amount of payment necessary to satisfy these provi-
1. In the case of a claim involving expenses for a Dependent sions, Blue Shield shall have the right to recover the excess
child whose parents are separated or divorced, plans cov- from any person or other entity to or with respect to whom
ering the child as a Dependent shall determine their re- such payments were made.
spective benefits in the following order: First, the plan of
Blue Shield may release to or obtain from any organization or
the parent with custody of the child; then, if that parent
person any information which Blue Shield considers necessary
has remarried, the plan of the stepparent with custody of
for the purpose of determining the applicability of and imple-
the child; and finally the plan(s) of the parent(s) without
menting the terms of these provisions or any provisions of
custody of the child.
similar purpose of any other plan. Any person claiming Bene-
2. Notwithstanding (1.) above, if there is a court decree fits under this Plan shall furnish Blue Shield with such infor-
which otherwise establishes financial responsibility for mation as may be necessary to implement these provisions.
the medical, dental or other health care expenses of the
child, then the plan which covers the child as a Depend- TERMINATION OF BENEFITS
ent of the parent with that financial responsibility shall
determine its benefits before any other plan which covers AND CANCELLATION PROVISIONS
the child as a Dependent child.
TERMINATION OF BENEFITS
3. If the above rules do not apply, the plan which has cov-
ered the patient for the longer period of time shall deter- Coverage for you or your Dependents terminates at 12:01 a.m.
mine its benefits first, provided that: Pacific Time on the earliest of these dates: (1) the date the
Group Health Service Contract is discontinued, (2) the last
a. a plan covering a patient as a laid-off or retired em- day of the month in which the Subscriber’s employment ter-
ployee, or as a Dependent of such an employee, shall minates, unless a different date has been agreed to between
determine its benefits after any other plan covering Blue Shield and your Employer, (3) fifteen (15) days follow-
that person as an employee, other than a laid-off or ing the date of mailing of the notice to the Employer that Dues
retired employee, or such Dependent; and, are not paid (see Cancellation for Non-Payment of Dues -
Notices), or (4) on the last day of the month in which you or
b. if either plan does not have a provision regarding
your Dependents become ineligible. A spouse also becomes
laid-off or retired employees, which results in each
ineligible following legal separation from the Subscriber, en-
plan determining its benefits after the other, then the
try of a final decree of divorce, annulment, or dissolution of
provisions of (a.) above shall not apply.
marriage from the Subscriber. A Domestic Partner becomes
If this Plan is the primary carrier with respect to a covered ineligible upon termination of the domestic partnership.
person, then this Plan will provide its Benefits without reduc-
Except as specifically provided under the Extension of Bene-
tion because of benefits available from any other plan.
fits and Group Continuation Coverage provisions, there is no
When this Plan is secondary in the order of payments, and right to receive benefits for services provided following ter-
Blue Shield is notified that there is a dispute as to which plan mination of this group Contract.
is primary, or that the primary plan has not paid within a rea-
If you cease work because of retirement, disability, leave of
sonable period of time, this Plan will provide the Benefits that
absence, temporary layoff, or termination, see your Employer
would be due as if it were the primary plan, provided that the
about possibly continuing group coverage. Also, see the
covered person (1) assigns to Blue Shield the right to receive
Group Continuation Coverage and Individual Conversion Plan
benefits from the other plan to the extent of the difference
section for information on continuation of coverage.
between the value of the Benefits which Blue Shield actually
provides and the value of the Benefits that Blue Shield would If your Employer is subject to the California Family Rights
have been obligated to provide as the secondary plan, (2) Act of 1991 and/or the federal Family and Medical Leave Act
agrees to cooperate fully with Blue Shield in obtaining pay- of 1993, and the approved leave of absence is for family leave
ment of benefits from the other plan, and (3) allows Blue under the terms of such Act(s), your payment of Dues will
Shield to obtain confirmation from the other plan that the keep your coverage in force for such period of time as speci-
Benefits which are claimed have not previously been paid. fied in such Act(s). Your Employer is solely responsible for
notifying you of the availability and duration of family leaves.
If application is not made for a newborn or a child placed for CANCELLATION WITHOUT CAUSE
adoption within the 31 days following that Dependent’s effec-
tive date of coverage, Benefits under this Plan will be termi- The group Contract may be cancelled by your Employer at
nated on the 32nd day at 12:01 a.m. Pacific Time. any time provided written notice is given to Blue Shield to
become effective upon receipt, or on a later date as may be
If the Subscriber no longer lives or works in the Plan Service specified on the notice.
Area, coverage will be terminated for him and all his Depend-
ents. If a Dependent no longer lives or works in the Plan Ser- CANCELLATION FOR NON-PAYMENT OF DUES -
vice Area, then that Dependent’s coverage will be terminated.
(Special arrangements may be available for Dependents who
are full-time students or do not live in the Subscriber’s home. Blue Shield may cancel this group Contract for non-payment
Please contact the Member Services Department to request an of Dues. If your Employer fails to pay the required Dues
Away From Home Care® Program Brochure which explains when due, Blue Shield of California will mail your Employer
these arrangements.) a Prospective Notice of Cancellation at least 15 days before
any cancellation of coverage. This notice will provide infor-
Additionally, the Plan may terminate coverage of a Member
mation to your Employer regarding the consequences of your
for cause immediately upon written notice for the following:
Employer’s failure to pay the Dues due within 15 days of the
1. Material information that is false or misrepresented in- date the notice was mailed.
formation provided on the enrollment application or
If payment is not received from your Employer within 15 days
given to the group or the Plan; see the Cancella-
of the date the Prospective Notice of Cancellation is mailed,
tion/Rescission for Fraud, Misrepresentations or Omis-
Blue Shield of California will cancel the Group Health Ser-
vice Contract at the end of that 15-day period and coverage
2. Permitting a non-Member to use a Member identification for you and all your Dependents will end on that date. Blue
card to obtain Services and Benefits; Shield of California will send your Employer a Notice Con-
firming Termination of Coverage. Your Employer must pro-
3. Obtaining or attempting to obtain Services or Benefits
vide you with a copy of the Notice Confirming Termination of
under the Group Health Service Contract by means of
false, materially misleading, or fraudulent information,
acts or omissions; In addition, Blue Shield of California will send you a HIPAA
certificate which will state the date on which your coverage
4. Abusive or disruptive behavior which: (1) threatens the
terminated, the reason for the termination, and the number of
life or well-being of the Plan personnel and providers of
months of creditable coverage which you have. The certifi-
Services, or, (2) substantially impairs the ability of Blue
cate will also summarize your rights for continuing coverage
Shield of California to arrange for Services to the Mem-
on a guaranteed issue basis under HIPAA and on Blue Shield
ber, or, (3) substantially impairs the ability of providers
of California’s conversion plan. For more information on
of Service to furnish Services to the Member or to other
conversion coverage and your rights to HIPAA coverage,
please see the paragraph on Availability of Blue Shield of
The Plan may also terminate coverage of a Member for cause California Individual Plans.
upon 31 days written notice for the following:
CANCELLATION/RESCISSION FOR FRAUD,
1. Inability to establish a satisfactory Physician-patient rela-
tionship after following the procedures under Relation- MISREPRESENTATIONS OR OMISSIONS
ship with Your Personal Physician in the Choice of Phy- Blue Shield may cancel the group Contract for fraud or mis-
sicians and Providers section; representation by your Employer, or with respect to coverage
2. Failure to pay any Copayment or supplemental charge. of Employees or Dependents, for fraud or misrepresentation
of the Employee, Dependent, or their representative.
REINSTATEMENT If you are hospitalized or undergoing treatment for an ongoing
condition and the group Contract is cancelled for any reason,
If you had been making contributions toward cov- including non-payment of Dues, no Benefits will be provided
erage for you and your Dependents and voluntarily unless you obtain an Extension of Benefits.
cancelled such coverage, you may apply for rein-
Misrepresentations or omissions on an application or a health
statement. You or your Dependents must wait until statement (if a health statement is required by the Employer)
the earlier of, 12 months from the date of applica- may result in the cancellation or rescission of this Plan. Can-
tion or at the Employer’s next Open Enrollment cellations are effective on receipt or on such later date as
Period to be reinstated. Blue Shield will not con- specified in the cancellation notice.
sider applications for earlier effective dates.
In the event the Contract is rescinded or cancelled, either by 1. You failed to pay amounts due the Plan;
Blue Shield or your Employer, it is your Employer’s responsi-
2. You were terminated by the Plan for good cause or for
bility to notify you of the rescission or cancellation.
fraud or misrepresentation;
RIGHT OF CANCELLATION 3. You knowingly furnished incorrect information or other-
wise improperly obtained the Benefits of the Plan;
If you are making any contributions toward cover-
age for yourself or your Dependents, you may can- 4. You are covered or eligible for Medicare;
cel such coverage to be effective at the end of any 5. You are covered or eligible for Hospital, medical or sur-
period for which Dues have been paid. gical benefits under state or federal law or under any ar-
rangement of coverage for individuals in a group,
If your Employer does not meet the applicable eli- whether insured or self-insured; and,
gibility, participation and contribution requirements 6. You are covered for similar benefits under an individual
of the group contract, Blue Shield of California will policy or contract.
cancel this Plan after 30 days’ written notice to Benefits or rates of an individual conversion health plan are
your Employer. different from those in your group Plan.
Any Dues paid Blue Shield for a period extending An individual conversion health Plan is also available to:
beyond the cancellation date will be refunded to 1. Dependents, if the Subscriber dies;
your Employer. Your Employer will be responsi-
2. Dependents who marry or exceed the maximum age for
ble to Blue Shield for unpaid Dues prior to the date Dependent coverage under the group Plan;
3. Dependents, if the Subscriber enters military service;
Blue Shield will honor all claims for Covered Ser- 4. Spouse or Domestic Partner of a Subscriber, if their mar-
vices provided prior to the effective date of cancel- riage or domestic partnership has terminated;
5. Dependents, when continuation of coverage under CO-
See the Cancellation/Rescission for Fraud, Misrep- BRA and/or Cal-COBRA expires, or is terminated.
resentations or Omissions provision for termination When a Dependent reaches the limiting age for coverage as a
for misrepresentations or omissions. Dependent, or if a Dependent becomes ineligible for any of
the other reasons given above, it is your responsibility to in-
GROUP CONTINUATION COVERAGE AND form Blue Shield. Upon receiving notification, Blue Shield
will offer such Dependent an individual conversion health plan
INDIVIDUAL CONVERSION PLAN for purposes of continuous coverage.
INDIVIDUAL CONVERSION PLAN GUARANTEED ISSUE INDIVIDUAL COVERAGE
Regardless of age, physical condition or employment status, Under the Health Insurance Portability and Accountability Act
you may continue Blue Shield protection when you retire, of 1996 (HIPAA) and under California law, you may be enti-
leave the job or become ineligible for group coverage. If you tled to apply for certain of Blue Shield’s individual health
have held group coverage for 3 or more consecutive months, plans on a guaranteed issue basis (which means that you will
you and your enrolled Dependents may apply to transfer to an not be rejected for underwriting reasons if you meet the other
individual conversion health plan then being issued by Blue eligibility requirements, you live or work in Blue Shield’s
Shield. Your Employer is solely responsible for notifying you Service Area and you agree to pay all required Dues). You
of the availability, terms and conditions of the individual con- may also be eligible to purchase similar coverage on a guaran-
version plan within 15 days of termination of the Contract’s teed issue basis from any other health plan that sells individual
coverage. coverage for hospital, medical or surgical benefits. Not all
An application and first Dues payment for the conversion plan Blue Shield individual plans are available on a guaranteed
must be received by Blue Shield within 63 days of the date of issue basis under HIPAA. To be eligible, you must meet the
termination of your group coverage. However, if the group following requirements:
Contract is replaced by your Employer with similar coverage • You must have at least 18 or more months of creditable
under another contract within 15 days, transfer to the individ- coverage.
ual conversion health plan will not be permitted. You will not
be permitted to transfer to the individual conversion plan un- • Your most recent coverage must have been group cover-
der any of the following circumstances: age (COBRA and Cal-COBRA are considered group
coverage for these purposes).
• You must have elected and exhausted all COBRA and/or a Qualifying Event that occurs while the Contractholder is
Cal-COBRA coverage that is available to you. subject to the continuation of group coverage provisions of
COBRA or Cal-COBRA.
• You must not be eligible for nor have any other health
insurance coverage, including a group health plan, Medi- The Benefits under the group continuation of coverage will be
care or Medi-Cal. identical to the Benefits that would be provided to the Mem-
ber if the Qualifying Event had not occurred (including any
• You must make application to Blue Shield for guaranteed changes in such coverage).
issue coverage within 63 days of the date of termination
from the group plan. Note: A Member will not be entitled to benefits under Cal-
COBRA if at the time of the qualifying event such Member is
If you elect Conversion Coverage, Continuation of Group entitled to benefits under Title XVIII of the Social Security
Coverage After COBRA and/or Cal-COBRA, or other Blue Act (“Medicare”) or is covered under another group health
Shield individual plans, you will waive your right to this guar- plan that provides coverage without exclusions or limitations
anteed issue coverage. For more information, contact a Blue with respect to any pre-existing condition. Under COBRA, a
Shield Member Services representative at the telephone num- Member is entitled to benefits if at the time of the qualifying
ber noted on your ID Card. event such Member is entitled to Medicare or has coverage
under another group health plan. However, if Medicare enti-
EXTENSION OF BENEFITS tlement or coverage under another group health plan arises
If a person becomes Totally Disabled while validly covered after COBRA coverage begins, it will cease.
under this Plan and continues to be Totally Disabled on the
date the group Contract terminates, Blue Shield will extend Qualifying Event
the Benefits of this Plan, subject to all limitations and restric- A Qualifying Event is defined as a loss of coverage as a result
tions, for Covered Services and supplies directly related to the of any one of the following occurrences:
condition, illness or injury causing such Total Disability until
the first to occur of the following: (1) the date the covered 1. With respect to the Subscriber:
person is no longer Totally Disabled; (2) 12:00 a.m. Pacific
a. the termination of employment (other than by reason
Time on the day following a period of 12 months from the
of gross misconduct); or
date the group Contract terminated; (3) the date on which the
covered person’s maximum Benefits are reached; (4) the date b. the reduction of hours of employment to less than the
on which a replacement carrier provides coverage to the per- number of hours required for eligibility.
son without limitation as to the Totally Disabling condition.
2. With respect to the Dependent spouse or Dependent Do-
Written certification of the Member’s Total Disability should mestic Partner* and Dependent children (children born to
be submitted to Blue Shield by the Member’s Personal Physi- or placed for adoption with the Subscriber or Domestic
cian as soon as possible after the Group Health Service Con- Partner during a COBRA or Cal-COBRA continuation
tract terminates. Proof of continuing Total Disability must be period may be added as Dependents, provided the Con-
furnished by the Member’s Personal Physician at reasonable tractholder is properly notified of the birth or placement
intervals determined by Blue Shield. for adoption, and such children are enrolled within 30
days of the birth or placement for adoption):
GROUP CONTINUATION COVERAGE
*Note: Domestic Partners and Dependent children of
Please examine your options carefully before declining this Domestic Partners cannot elect COBRA on their own,
coverage. You should be aware that companies selling indi- and are only eligible for COBRA if the Subscriber elects
vidual health insurance typically require a review of your to enroll. Domestic Partners and Dependent children of
medical history that could result in a higher premium or you Domestic Partners may elect to enroll in Cal-COBRA on
could be denied coverage entirely. their own.
Applicable to Members when the Subscriber’s Employer a. the death of the Subscriber; or
(Contractholder) is subject to either Title X of the Consoli-
dated Omnibus Budget Reconciliation Act (COBRA) as b. the termination of the Subscriber’s employment
amended or the California Continuation Benefits Replacement (other than by reason of such Subscriber’s gross mis-
Act (Cal-COBRA). The Subscriber’s Employer should be conduct); or
contacted for more information.
c. the reduction of the Subscriber’s hours of employ-
In accordance with the Consolidated Omnibus Budget Recon- ment to less than the number of hours required for
ciliation Act (COBRA) as amended and the California Con- eligibility; or
tinuation Benefits Replacement Act (Cal-COBRA), a Member
will be entitled to elect to continue group coverage under this
Plan if the Member would lose coverage otherwise because of
d. the divorce or legal separation of the Dependent qualify the Member from receiving continuation coverage
spouse from the Subscriber or termination of the under Cal-COBRA.
domestic partnership; or
The Employer is responsible for notifying Blue Shield in writ-
e. the Subscriber’s entitlement to benefits under Title ing of the Subscriber’s termination or reduction of hours of
XVIII of the Social Security Act (“Medicare”); or employment within 30 days of the Qualifying Event.
f. a Dependent child’s loss of Dependent status under When Blue Shield is notified that a Qualifying Event has oc-
this Plan. curred, Blue Shield will, within 14 days, provide written no-
tice to the Member by first class mail of the Member’s right to
3. For COBRA only, with respect to a Subscriber who is continue group coverage under this Plan. The Member must
covered as a retiree, that retiree’s Dependent spouse and then give Blue Shield notice in writing of the Member’s elec-
Dependent children, when the Employer files for reor- tion of continuation coverage within 60 days of the later of (1)
ganization under Title XI, United States Code, commenc- the date of the notice of the Member’s right to continue group
ing on or after July 1, 1986. coverage or (2) the date coverage terminates due to the Quali-
4. Such other Qualifying Event as may be added to Title X fying Event. The written election notice must be delivered to
of COBRA or the California Continuation Benefits Re- Blue Shield by first-class mail or other reliable means.
placement Act (Cal-COBRA). If the Member does not notify Blue Shield within 60 days, the
Member’s coverage will terminate on the date the Member
Notification of a Qualifying Event would have lost coverage because of the Qualifying Event.
1. With respect to COBRA enrollees: If this Plan replaces a previous group plan that was in effect
The Member is responsible for notifying the Employer of di- with the Employer, and the Member had elected Cal-COBRA
vorce, legal separation, or a child’s loss of Dependent status continuation coverage under the previous plan, the Member
under this Plan, within 60 days of the date of the later of the may choose to continue to be covered by this Plan for the bal-
Qualifying Event or the date on which coverage would other- ance of the period that the Member could have continued to
wise terminate under this Plan because of a Qualifying Event. be covered under the previous plan, provided that the Member
notify Blue Shield within 30 days of receiving notice of the
The Employer is responsible for notifying its COBRA admin- termination of the previous group plan.
istrator (or Plan administrator if the Employer does not have a
COBRA administrator) of the Subscriber’s death, termination, Duration and Extension
or reduction of hours of employment, the Subscriber’s Medi- of Continuation of Group Coverage
care entitlement, or the Employer’s filing for reorganization
under Title XI, United States Code. Cal-COBRA enrollees will be eligible to continue Cal-
COBRA coverage under this Plan for up to a maximum of 36
When the COBRA administrator is notified that a Qualifying months regardless of the type of Qualifying Event.
Event has occurred, the COBRA administrator will, within 14
days, provide written notice to the Member by first class mail COBRA enrollees who reach the 18-month or 29-month
of the Member’s right to continue group coverage under this maximum available under COBRA, may elect to continue
Plan. coverage under Cal-COBRA for a maximum period of 36
months from the date the Member’s continuation coverage
The Member must then notify the COBRA administrator began under COBRA. If elected, the Cal-COBRA coverage
within 60 days of the later of (1) the date of the notice of the will begin after the COBRA coverage ends.
Member’s right to continue group coverage or (2) the date
coverage terminates due to the Qualifying Event. Note: COBRA enrollees must exhaust all the COBRA cover-
age to which they are entitled before they can become eligible
If the Member does not notify the COBRA administrator to continue coverage under Cal-COBRA.
within 60 days, the Member’s coverage will terminate on the
date the Member would have lost coverage because of the In no event will continuation of group coverage under CO-
Qualifying Event. BRA, Cal-COBRA or a combination of COBRA and Cal-
COBRA be extended for more than 3 years from the date the
2. With respect to Cal-COBRA enrollees: Qualifying Event has occurred which originally entitled the
The Member is responsible for notifying Blue Shield in writ- Member to continue group coverage under this Plan.
ing of the Subscriber’s death or Medicare entitlement, of di- Note: Domestic Partners and Dependent children of Domestic
vorce, legal separation, termination of a domestic partnership Partners cannot elect COBRA on their own, and are only eli-
or a child’s loss of Dependent status under this Plan. Such gible for COBRA if the Subscriber elects to enroll. Domestic
notice must be given within 60 days of the date of the later of Partners and Dependent children of Domestic Partners may
the Qualifying Event or the date on which coverage would elect to enroll in Cal-COBRA on their own.
otherwise terminate under this Plan because of a Qualifying
Event. Failure to provide such notice within 60 days will dis-
Notification Requirements for Employees, the Member may be able to continue cov-
erage with another plan);
The Employer or its COBRA administrator is responsible for
notifying COBRA enrollees of their right to possibly continue 2. failure to timely and fully pay the amount of required
coverage under Cal-COBRA at least 90 calendar days before dues to the COBRA administrator or the Employer or to
their COBRA coverage will end. The COBRA enrollee Blue Shield of California as applicable. Coverage will
should contact Blue Shield for more information about con- end as of the end of the period for which dues were paid;
tinuing coverage. If the enrollee elects to apply for continua- 3. the Member becomes covered under another group health
tion of coverage under Cal-COBRA, the enrollee must notify plan that does not include a pre-existing condition exclu-
Blue Shield at least 30 days before COBRA termination. sion or limitation provision that applies to the Member;
Payment of Dues 4. the Member becomes entitled to Medicare;
Dues for the Member continuing coverage shall be 102 per- 5. the Member no longer resides in Blue Shield’s Service
cent of the applicable group dues rate if the Member is a CO- Area;
BRA enrollee or 110 percent of the applicable group dues rate 6. the Member commits fraud or deception in the use of the
if the Member is a Cal-COBRA enrollee, except for the Services of this Plan.
Member who is eligible to continue group coverage to 29
months because of a Social Security disability determination, Continuation of group coverage in accordance with COBRA
in which case, the dues for months 19 through 29 shall be 150 or Cal-COBRA will not be terminated except as described in
percent of the applicable group dues rate. this provision. In no event will coverage extend beyond 36
Note: For COBRA enrollees who are eligible to extend group
coverage under COBRA to 29 months because of a Social CONTINUATION OF GROUP COVERAGE
Security disability determination, dues for Cal-COBRA cov-
FOR MEMBERS ON MILITARY LEAVE
erage shall be 110 percent of the applicable group dues rate
for months 30 through 36. Continuation of group coverage is available for Members on
military leave if the Member’s Employer is subject to the Uni-
If the Member is enrolled in COBRA and is contributing to
formed Services Employment and Re-employment Rights Act
the cost of coverage, the Employer shall be responsible for
(USERRA). Members who are planning to enter the Armed
collecting and submitting all dues contributions to Blue Shield
Forces should contact their Employer for information about
in the manner and for the period established under this Plan.
their rights under the USERRA. Employers are responsible to
Cal-COBRA enrollees must submit dues directly to Blue ensure compliance with this act and other state and federal
Shield of California. The initial dues must be paid within 45 laws regarding leaves of absence including the California
days of the date the Member provided written notification to Family Rights Act, the Family and Medical Leave Act, Labor
the Plan of the election to continue coverage and be sent to Code requirements for Medical Disability.
Blue Shield by first-class mail or other reliable means. The
dues payment must equal an amount sufficient to pay any re- CONTINUATION OF GROUP COVERAGE
quired amounts that are due. Failure to submit the correct AFTER COBRA AND/OR CAL-COBRA
amount within the 45-day period will disqualify the Member
from continuation coverage. The following section only applies to enrollees who became
eligible for Continuation of Group Coverage After COBRA
Effective Date of the Continuation of and/or Cal-COBRA prior to January 1, 2005:
Coverage Certain former Employees and their Dependent spouses or
Dependent Domestic Partners (including a spouse who is di-
The continuation of coverage will begin on the date the Mem-
vorced from the current Employee/former Employee and/or a
ber’s coverage under this Plan would otherwise terminate due
spouse who was married to the Employee/former Employee at
to the occurrence of a Qualifying Event and it will continue
the time of that Employee/former Employee’s death, or a Do-
for up to the applicable period, provided that coverage is
mestic Partner whose partnership with the current Em-
timely elected and so long as dues are timely paid.
ployee/former Employee has terminated and/or a Domestic
Partner who was in a Domestic Partner relationship with the
Termination of Continuation of Group Employee/former Employee at the time of that Em-
Coverage ployee/former Employee’s death) may be eligible to continue
The continuation of group coverage will cease if any one of group coverage beyond the date their COBRA and/or Cal-
the following events occurs prior to the expiration of the ap- COBRA coverage ends. Blue Shield will offer the extended
plicable period of continuation of group coverage: coverage to former Employees of employers that are subject
to the existing COBRA or Cal-COBRA, and to the former
1. discontinuance of this Group Health Service Contract (if Employees’ Dependent spouses, including divorced or wid-
the Employer continues to provide any group benefit plan
owed spouses as defined above, or Dependent Domestic Part- the other health plan are less valuable than those of the
ners, including surviving Domestic Partners or Domestic Part- health plan maintained by the Employer;
ners whose partnership was terminated as defined above. This
4. the date the former Employee, spouse, or Domestic Part-
coverage is subject to the following conditions:
ner or former spouse or former Domestic Partner be-
1. The former Employee worked for the Employer for the comes entitled to Medicare;
prior 5 years and was 60 years of age or older on the date
5. for a spouse or Domestic Partner or former spouse or
his/her employment ended.
former Domestic Partner, 5 years from the date the
2. The former Employee was eligible for and elected CO- spouse’s or Domestic Partner’s COBRA or Cal-COBRA
BRA and/or Cal-COBRA for himself and his Dependent coverage would end.
spouse (a former spouse, i.e., a divorced or widowed
spouse as defined above, is also eligible for continuation AVAILABILITY OF BLUE SHIELD OF CALIFORNIA
of group coverage after COBRA and/or Cal-COBRA). INDIVIDUAL PLANS
3. The former Employee was eligible for and elected CO- Blue Shield’s Individual Plans described at the beginning of
BRA and/or Cal-COBRA for himself and his Dependent this section may be available to Members whose group cover-
Domestic Partner (a former Domestic Partner, i.e., a sur- age, COBRA or Cal-COBRA coverage, or Continuation of
viving Domestic Partner or Domestic Partner whose part- Group Coverage After COBRA and/or Cal-COBRA is termi-
nership has been terminated as defined above, is also eli- nated or expires while covered under this group Plan. Note:
gible for continuation of group coverage after COBRA Only Individual Conversion Coverage is available to Mem-
and/or Cal-COBRA). bers who are terminated from Continuation of Group Cover-
Items 1., 2. and 3. above are not applicable to a former spouse age After COBRA and/or Cal-COBRA.
or former Domestic Partner electing continuation coverage.
The former spouse or former Domestic Partner must elect OTHER PROVISIONS
such coverage by notifying the Plan in writing within 30 cal-
endar days prior to the date that the former spouse’s or former PUBLIC POLICY PARTICIPATION PROCEDURE
Domestic Partner’s initial COBRA and/or Cal-COBRA bene-
fits are scheduled to end. This procedure enables you to participate in establishing pub-
lic policy of Blue Shield of California. It is not to be used as a
If elected, this coverage will begin after the COBRA and/or Cal- substitute for the grievance procedure, complaints, inquiries or
COBRA coverage ends and will be administered under the same requests for information.
terms and conditions as if COBRA and/or Cal-COBRA had
remained in force. Public policy means acts performed by a plan or its employees
and staff to assure the comfort, dignity, and convenience of
For Members who transfer to this coverage from COBRA, patients who rely on the plan’s facilities to provide health care
dues for this coverage shall be 213 percent of the applicable services to them, their families, and the public (Health and
group dues rate, or 102 percent of the applicable age adjusted Safety Code, Section 1369).
group dues rate. For Members who transfer to this coverage
from Cal-COBRA, dues for this coverage shall be 213 percent At least one third of the Board of Directors of Blue Shield is
of the applicable group dues rate, or 110 percent of the appli- comprised of Subscribers who are not employees, providers,
cable age adjusted group dues rate. Payment is due at the time subcontractors or group contract brokers and who do not have
the Employer’s payment is due. financial interests in Blue Shield. The names of the members
of the Board of Directors may be obtained from:
Termination of Continuation Coverage
Sr. Manager, Regulatory Filings
After COBRA and/or Cal-COBRA Blue Shield of California
This coverage will end automatically on the earliest of the 50 Beale Street
following dates: San Francisco, CA 94105
Phone Number: 1-415-229-5065
1. the date the former Employee, spouse, or Domestic Part-
ner or former spouse or former Domestic Partner reaches Please follow the following procedure:
65; 1. Your recommendations, suggestions or comments should
2. the date the Employer discontinues this Group Health be submitted in writing to the Sr. Manager, Regulatory
Service Contract and ceases to maintain any group health Filings, at the above address, who will acknowledge re-
plan for any active Employees; ceipt of your letter;
3. the date the former Employee, spouse, or Domestic Part- 2. Your name, address, phone number, Subscriber number,
ner or former spouse or former Domestic Partner trans- and group number should be included with each commu-
fers to another health plan, whether or not the benefits of nication;
3. The policy issue should be stated so that it will be readily to Blue Shield that information that is reasonably needed by
understood. Submit all relevant information and reasons Blue Shield. You agree to assist Blue Shield in obtaining this
for the policy issue with your letter; information, if needed, (including signing any necessary au-
thorizations) and to cooperate by providing Blue Shield with
4. Policy issues will be heard at least quarterly as agenda
information in your possession. Failure to assist Blue Shield
items for meetings of the Board of Directors. Minutes of
in obtaining necessary information or refusal to provide in-
Board meetings will reflect decisions on public policy is-
formation reasonably needed may result in the delay or denial
sues that were considered. If you have initiated a policy
of benefits until the necessary information is received. Any
issue, appropriate extracts of the minutes will be fur-
information received for this purpose by Blue Shield will be
nished to you within 10 business days after the minutes
maintained as confidential and will not be disclosed without
have been approved.
your consent, except as otherwise permitted by law.
CONFIDENTIALITY OF PERSONAL AND HEALTH NON-ASSIGNABILITY
Benefits of this Plan are not assignable.
Blue Shield of California protects the confidentiality/privacy
of your personal and health information. Personal and health PLEASE READ THE FOLLOWING INFORMATION SO
information includes both medical information and individu- YOU WILL KNOW FROM WHOM OR WHAT GROUP
ally identifiable information, such as your name, address, tele- OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
phone number, or social security number. Blue Shield will
not disclose this information without your authorization, ex- FACILITIES
cept as permitted by law. The Plan has established a network of Physicians, Hospitals,
A STATEMENT DESCRIBING BLUE SHIELD'S Participating Hospice Agencies and Non-Physician Health
Care Practitioners in your Personal Physician Service Area.
POLICIES AND PROCEDURES FOR PRE-
SERVING THE CONFIDENTIALITY OF The Personal Physician(s) you and your Dependents select
MEDICAL RECORDS IS AVAILABLE AND will provide telephone access 24 hours a day, 7 days a week
so that you can obtain assistance and prior approval of Medi-
WILL BE FURNISHED TO YOU UPON RE- cally Necessary care. The Hospitals in the Plan network pro-
QUEST. vide access to 24-hour Emergency Services. The list of the
Blue Shield’s policies and procedures regarding our confidenti- Hospitals, Physicians and Participating Hospice Agencies in
ality/privacy practices are contained in the “Notice of Privacy your Personal Physician Service Area indicates the location
Practices”, which you may obtain either by calling the Member and phone numbers of these Providers. Contact Member Ser-
Services Department at the number provided on the last page of vices at the number provided on the last page of this booklet
this booklet, or by accessing Blue Shield of California’s Internet for information on Plan Non-Physician Health Care Practitio-
site located at http://www.blueshieldca.com and printing a copy. ners in your Personal Physician Service Area.
If you are concerned that Blue Shield may have violated your For Urgent Services when you are within the United States,
confidentiality/privacy rights, or you disagree with a decision you simply call toll-free 1-800-810-BLUE (2583) 24 hours a
we made about access to your personal and health informa- day, 7 days a week. For Urgent Services when you are out-
tion, you may contact us at: side the United States, you can call collect 1-804-673-1177 24
hours a day. We will identify the BlueCard Program provider
Correspondence Address: closest to you. Urgent Services when you are outside the U.S.
Blue Shield of California Privacy Official are available through the BlueCard Worldwide Network. For
P.O. Box 272540 Urgent Services when you are within California, but outside of
Chico, CA 95927-2540 your Personal Physician Service Area, you should, if possible,
contact your Personal Physician or Blue Shield Member Ser-
Toll-Free Telephone: vices at the number listed on the last page of this booklet in
1-888-266-8080 accordance with the How to Use Your Health Plan section.
For Urgent Services when you are within your Personal Phy-
Email Address: sician Service Area, contact your Personal Physician to obtain
email@example.com Urgent Services which must be provided or authorized by
your Personal Physician just like all other non-Emergency
Services of the Plan.
ACCESS TO INFORMATION
Blue Shield of California may need information from medical INDEPENDENT CONTRACTORS
providers, from other carriers or other entities, or from you, in
order to administer benefits and eligibility provisions of this Plan Providers are neither agents nor employees of the Plan
Contract. You agree that any provider or entity can disclose but are independent contractors. Blue Shield of California
conducts a process of credentialing and certification of all Note: Blue Shield of California has established a procedure
Physicians who participate in the Access+ HMO Network. for our Members to request an expedited decision. A Mem-
However, in no instance shall the Plan be liable for the negli- ber, Physician, or representative of a Member may request an
gence, wrongful acts or omissions of any person receiving or expedited decision when the routine decision making process
providing Services, including any Physician, Hospital, or might seriously jeopardize the life or health of a Member, or
other provider or their employees. when the Member is experiencing severe pain. Blue Shield
shall make a decision and notify the Member and Physician as
PAYMENT OF PROVIDERS soon as possible to accommodate the Member’s condition not
to exceed 72 hours following the receipt of the request. An
Blue Shield generally contracts with groups of Physicians to
expedited decision may involve admissions, continued stay, or
provide Services to Members. A fixed, monthly fee is paid to
other healthcare services. If you would like additional infor-
the groups of Physicians for each Member whose Personal
mation regarding the expedited decision process, or if you
Physician is in the group. This payment system, capitation,
believe your particular situation qualifies for an expedited
includes incentives to the groups of Physicians to manage all
decision, please contact our Member Services Department at
Services provided to Members in an appropriate manner con-
the number listed on the last page of this booklet.
sistent with the contract.
If you want to know more about this payment system, contact For all Mental Health and substance abuse
Member Services at the number listed on the last page of this Services
booklet. For all Mental Health and substance abuse Services, Blue
Shield of California has contracted with the Plan’s MHSA.
PLAN INTERPRETATION The MHSA should be contacted for questions about Mental
Blue Shield shall have the power and discretionary authority Health and substance abuse Services, MHSA Participating
to construe and interpret the provisions of the Contract, to Providers, or Mental Health and substance abuse Benefits.
determine the Benefits of the Contract, and determine eligibil- You may contact the MHSA at the telephone number or ad-
ity to receive Benefits under the Contract. Blue Shield shall dress which appear below:
exercise this authority for the benefit of all persons entitled to 1-877-263-9952
receive Benefits under the Contract.
Blue Shield of California
Mental Health Service Administrator
3111 Camino Del Rio North, Suite 600
You may provide Blue Shield with feedback regarding the San Diego, CA 92108
service you receive from Plan Physicians. Return the prepaid
The MHSA can answer many questions over the telephone.
postcard available from Member Services to Blue Shield. If
you are dissatisfied with the service provided during an office Note: The MHSA has established a procedure for our Mem-
visit with a Plan Physician, you may request a refund of your bers to request an expedited decision. A Member, Physician,
office visit Copayment, as shown in the Summary of Benefits or representative of a Member may request an expedited deci-
under Professional (Physician) Services. sion when the routine decision making process might seriously
jeopardize the life or health of a Member, or when the Mem-
MEMBER SERVICES ber is experiencing severe pain. The MHSA shall make a
decision and notify the Member and Physician as soon as pos-
For all Services other than Mental Health and sible to accommodate the Member’s condition not to exceed
substance abuse 72 hours following the receipt of the request. An expedited
decision may involve admissions, continued stay, or other
If you have a question about Services, providers, Benefits, healthcare services. If you would like additional information
how to use your Plan, or concerns regarding the quality of regarding the expedited decision process, or if you believe
care or access to care that you have experienced, you may call your particular situation qualifies for an expedited decision,
Blue Shield’s Member Services Department at the number please contact the MHSA at the number listed above.
listed on the last page of this booklet.
The hearing impaired may contact Blue Shield's Member Ser- GRIEVANCE PROCESS
vices Department through Blue Shield's toll-free TTY num-
ber, 1-800-241-1823. Blue Shield of California has established a grievance proce-
dure for receiving, resolving and tracking Members’ griev-
You also may write to the Blue Shield Member Services De- ances with Blue Shield of California.
partment as noted on the last page of this booklet.
Member Services can answer many questions over the tele-
For all Services other than Mental Health and P. O. Box 880609
substance abuse San Diego, CA 92168
Members, a designated representative, or a provider on behalf The MHSA will acknowledge receipt of a grievance within 5
of the Member may contact the Member Services Department calendar days. Grievances are resolved within 30 days. The
by telephone, letter or online to request a review of an initial grievance system allows Members to file grievances for at
determination concerning a claim or service. Members may least 180 days following any incident or action that is the sub-
contact the Plan at the telephone number as noted on the last ject of the Member’s dissatisfaction. See the previous Mem-
page of this booklet. If the telephone inquiry to Member Ser- ber Services section for information on the expedited decision
vices does not resolve the question or issue to the Member’s process.
satisfaction, the Member may request a grievance at that time,
Note: If your Employer’s health Plan is governed by the Em-
which the Member Services Representative will initiate on the
ployee Retirement Income Security Act (“ERISA”), you may
have the right to bring a civil action under Section 502(a) of
The Member, a designated representative, or a provider on ERISA if all required reviews of your claim have been com-
behalf of the Member may also initiate a grievance by submit- pleted and your claim has not been approved. Additionally,
ting a letter or a completed “Grievance Form”. The Member you and your plan may have other voluntary alternative dis-
may request this form from Member Services. The completed pute resolution options, such as mediation.
form should be submitted to Member Services Appeals and
Grievance, P.O. Box 5588, El Dorado Hills, CA 95762-0011. EXTERNAL INDEPENDENT MEDICAL REVIEW
The Member may also submit the grievance online by visiting
If your grievance involves a claim or services for which cov-
erage was denied by Blue Shield or by a contracting Provider
Blue Shield will acknowledge receipt of a grievance within 5 in whole or in part on the grounds that the service is not
calendar days. Grievances are resolved within 30 days. The Medically Necessary or is Experimental/Investigational (in-
grievance system allows Members to file grievances for at cluding the external review available under the Friedman-
least 180 days following any incident or action that is the sub- Knowles Experimental Treatment Act of 1996), you may
ject of the Member’s dissatisfaction. See the previous Mem- choose to make a request to the Department of Managed
ber Services section for information on the expedited decision Health Care to have the matter submitted to an independent
process. agency for external review in accordance with California law.
You normally must first submit a grievance to Blue Shield and
For all Mental Health and substance abuse wait for at least 30 days before you request external review;
Services however, if your matter would qualify for an expedited deci-
Members, a designated representative, or a provider on behalf sion as described above or involves a determination that the
of the Member may contact the MHSA by telephone, letter or requested service is Experimental/Investigational, you may
online to request a review of an initial determination concern- immediately request an external review following receipt of
ing a claim or service. Members may contact the MHSA at notice of denial. You may initiate this review by completing
the telephone number as noted below. If the telephone inquiry an application for external review, a copy of which can be
to the MHSA’s Member Services Department does not re- obtained by contacting Member Services. The Department of
solve the question or issue to the Member’s satisfaction, the Managed Health Care will review the application and, if the
Member may request a grievance at that time, which the request qualifies for external review, will select an external
Member Services Representative will initiate on the Mem- review agency and have your records submitted to a qualified
ber’s behalf. specialist for an independent determination of whether the
care is Medically Necessary. You may choose to submit addi-
The Member, a designated representative, or a provider on tional records to the external review agency for review. There
behalf of the Member may also initiate a grievance by submit- is no cost to you for this external review. You and your Phy-
ting a letter or a completed “Grievance Form”. The Member sician will receive copies of the opinions of the external re-
may request this form from the MHSA’s Member Services view agency. The decision of the external review agency is
Department. If the Member wishes, the MHSA’s Member binding on Blue Shield; if the external reviewer determines
Services staff will assist in completing the Grievance Form. that the service is Medically Necessary, Blue Shield will
Completed grievance forms must be mailed to the MHSA at promptly arrange for the Service to be provided or the claim
the address provided below. The Member may also submit in dispute to be paid. This external review process is in addi-
the grievance to the MHSA online by visiting tion to any other procedures or remedies available to you and
http://www.blueshieldca.com. is completely voluntary on your part; you are not obligated to
1-877-263-9952 request external review. However, failure to participate in
external review may cause you to give up any statutory right
Blue Shield of California to pursue legal action against Blue Shield regarding the dis-
Mental Health Service Administrator puted service. For more information regarding the external
Attn: Customer Service
review process, or to request an application form, please con- on the lesser of the provider’s billed charges or a reasonable
tact Member Services. and customary amount, as determined by Blue Shield).
Ambulatory Surgery Center — an Outpatient surgery facil-
DEPARTMENT OF MANAGED HEALTH CARE ity which:
1. is either licensed by the state of California as an ambula-
The California Department of Managed Health Care is re- tory surgery center or is a licensed facility accredited by
sponsible for regulating health care service plans. If you have an ambulatory surgery center accrediting body; and,
a grievance against your health Plan, you should first tele-
phone your health Plan at the number provided on 2. provides services as a free-standing ambulatory surgery
center which is licensed separately and bills separately
the last page of this booklet and use your health Plan’s from a Hospital and is not otherwise affiliated with a
grievance process before contacting the Department. Utilizing Hospital.
this grievance procedure does not prohibit any potential legal
rights or remedies that may be available to you. If you need Benefits (Covered Services) — those Services which a
help with a grievance involving an emergency, a grievance Member is entitled to receive pursuant to the terms of the
that has not been satisfactorily resolved by your health Plan, Group Health Service Contract.
or a grievance that has remained unresolved for more than 30 Calendar Year — a period beginning 12:01 a.m., January 1
days, you may call the Department for assistance. You may and ending 12:01 a.m., January 1 of the following year.
also be eligible for an Independent Medical Review (IMR). If
you are eligible for IMR, the IMR process will provide an Close Relative — the spouse, Domestic Partner, child,
impartial review of medical decisions made by a health plan brother, sister, or parent of a Subscriber or Dependent.
related to the medical necessity of a proposed service or
Contract Year — a period beginning on July 1st of any year
treatment, coverage decisions for treatments that are experi-
and terminating on June 30th of the following year.
mental or investigational in nature and payment disputes for
emergency or urgent medical services. The Department also Copayment — the amount that a Member is required to pay
has a toll-free telephone number (1-888-HMO-2219) and for specific Covered Services after meeting any applicable
a TDD line (1-877-688-9891) for the hearing and speech Deductible.
impaired. The Department’s Internet Web site Cosmetic Surgery — surgery that is performed to alter or
(http://www.hmohelp.ca.gov) has complaint forms, reshape normal structures of the body to improve appearance.
IMR application forms and instructions online. Covered Services (Benefits) — those Services which a
In the event that Blue Shield should cancel or refuse to renew Member is entitled to receive pursuant to the terms of the
the enrollment for you or your Dependents and you feel that Group Health Service Contract.
such action was due to health or utilization of Benefits, you or Custodial or Maintenance Care — care furnished in the
your Dependents may request a review by the Department of home primarily for supervisory care or supportive services, or
Managed Health Care Director. in a facility primarily to provide room and board or meet the
Activities of Daily Living (which may include nursing care,
DEFINITIONS training in personal hygiene and other forms of self-care or
supervisory care by a Physician); or care furnished to a Mem-
Whenever any of the following terms are capitalized in this
ber who is mentally or physically disabled, and:
booklet, they will have the meaning stated below:
1. who is not under specific medical, surgical, or psychiatric
Access+ Provider — a Medical Group or IPA, and all asso-
treatment to reduce the disability to the extent necessary
ciated Physicians and Plan Specialists, that participate in the
to enable the patient to live outside an institution provid-
Access+ HMO Plan and for Mental Health and substance
ing such care; or,
abuse Services, an MHSA Participating Provider.
2. when, despite such treatment, there is no reasonable like-
Accidental Injury — definite trauma resulting from a sudden
lihood that the disability will be so reduced.
unexpected and unplanned event, occurring by chance, caused
by an independent external source. Deductible — the Contract Year amount which you must pay
for specific Covered Services that are a benefit of the Plan
Activities of Daily Living (ADL) — mobility skills required
before you become entitled to receive certain benefit pay-
for independence in normal everyday living. Recreational,
ments from the Plan for those Services.
leisure, or sports activities are not included.
Dental Care and Services — Services or treatment on or to
Allowed Charges — the amount a Plan Provider agrees to
the teeth or gums whether or not caused by Accidental Injury,
accept as payment from Blue Shield or the billed amount for
including any appliance or device applied to the teeth or
non-Plan Providers (except that Physicians rendering Emer-
gency Services who are not Plan Providers will be paid based
Dependent — a Subscriber's spouse, Domestic Partner or fessional medical standards, but nevertheless are authorized
unmarried child who are enrolled and accepted by Blue by law or by a government agency for use in testing, trials, or
Shield of California as a Dependent and who meet all of the other studies on human patients, shall be considered Experi-
Contractholder’s eligibility requirements. mental or Investigational in Nature.
Domestic Partner — an individual who is a Dependent of Family — the Subscriber and all enrolled Dependents.
the Subscriber and who meets all of the Contractholder’s
Group Health Service Contract (Contract) — the contract
issued by the Plan to the Contractholder that establishes the
Domiciliary Care — care provided in a Hospital or other Services Members are entitled to receive from the Plan.
licensed facility because care in the patient’s home is not
Hospice or Hospice Agency — an entity which provides
available or is unsuitable.
Hospice services to Terminally Ill persons and holds a license,
Dues — the monthly prepayment that is made to the Plan on currently in effect, as a Hospice pursuant to Health and Safety
behalf of each Member by the Contractholder. Code Section 1747, or a home health agency licensed pursu-
ant to Health and Safety Code Sections 1726 and 1747.1
Durable Medical Equipment — equipment designed for
which has Medicare certification.
repeated use which is Medically Necessary to treat an illness
or injury, to improve the functioning of a malformed body Hospital — either (1.), (2.) or (3.) below:
member, or to prevent further deterioration of the patient’s
1. a licensed and accredited health facility which is primar-
medical condition. Durable Medical Equipment includes
ily engaged in providing, for compensation from patients,
wheelchairs, Hospital beds, respirators, and other items that
medical, diagnostic, and surgical facilities for the care
the Plan determines are Durable Medical Equipment.
and treatment of sick and injured Members on an Inpa-
Emergency Services — Services provided for an unexpected tient basis, and which provides such facilities under the
medical condition, including a psychiatric emergency medical supervision of a staff of Physicians and 24 hour a day
condition, manifesting itself by acute symptoms of sufficient nursing service by registered nurses. A facility which is
severity (including severe pain) such that the absence of im- principally a rest home, nursing home or home for the
mediate medical attention could reasonably be expected to aged is not included;
result in any of the following:
2. a psychiatric Hospital licensed as a health facility accred-
1. placing the Member’s health in serious jeopardy; ited by the Joint Commission on Accreditation of Health
Care Organizations; or
2. serious impairment to bodily functions;
3. a “psychiatric health facility” as defined in Section
3. serious dysfunction of any bodily organ or part.
1250.2 of the Health and Safety Code.
Employee — an individual who meets the eligibility require-
Independent Practice Association (IPA) — a group of Phy-
ments set forth in the Group Health Service Contract between
sicians with individual offices who form an organization in
Blue Shield of California and your Employer.
order to contract, manage, and share financial responsibilities
Employer (Contractholder) — any person, firm, proprietary for providing Benefits to Members. For all Mental Health and
or non-profit corporation, partnership, public agency, or asso- substance abuse Services, this definition includes the MHSA.
ciation that has at least 2 Employees and that is actively en-
Infertility — either (1) the presence of a demonstrated bodily
gaged in business or service, in which a bona fide employer-
malfunction recognized by a licensed Physician as a cause of
employee relationship exists, in which the majority of Em-
Infertility, or (2) because of a demonstrated bodily malfunc-
ployees were employed within this state, and which was not
tion, the inability to conceive a pregnancy or to carry a preg-
formed primarily for purposes of buying health care coverage
nancy to a live birth after a year or more of regular sexual
relations without contraception, or (3) because of the inability
Experimental or Investigational in Nature — any treat- to conceive a pregnancy after six cycles of artificial insemina-
ment, therapy, procedure, drug or drug usage, facility or facil- tion. The initial six cycles are not a benefit of this Plan.
ity usage, equipment or equipment usage, device or device
Inpatient — an individual who has been admitted to a Hospi-
usage, or supplies which are not recognized in accordance
tal as a registered bed patient and is receiving Services under
with generally accepted professional medical standards as
the direction of a Physician.
being safe and effective for use in the treatment of the illness,
injury, or condition at issue. Services which require approval Intensive Outpatient Care Program — an Outpatient Men-
by the federal government or any agency thereof, or by any tal Health (or substance abuse) treatment program utilized
State government agency, prior to use and where such ap- when a patient’s condition requires structure, monitoring, and
proval has not been granted at the time the services or supplies medical/psychological intervention at least 3 hours per day, 3
were rendered, shall be considered Experimental or Investiga- times per week.
tional in Nature. Services or supplies which themselves are
not approved or recognized in accordance with accepted pro-
Late Enrollee — an eligible Employee or Dependent who has of a Refusal of Personal Coverage specifying that failure
declined enrollment in this Plan at the time of the initial en- to elect coverage during the initial enrollment period
rollment period, and who subsequently requests enrollment in permits the Plan to impose, at the time of his later deci-
this Plan; provided that the initial enrollment period shall be a sion to elect coverage, an exclusion from coverage for a
period of at least 30 days. However, an eligible Employee or period of 12 months, unless he or she meets the criteria
Dependent will not be considered a Late Enrollee if any of the specified in paragraphs (1.), (2.) or (3.) above; or
conditions listed under (1.), (2.), (3.), (4.), (5.), (6.) or (7.)
5. For eligible Dependents who have lost or will lose their
below is applicable:
no share-of-cost Medi-Cal coverage and who request en-
1. The eligible Employee or Dependent meets all of the rollment within 31 days after notification of this loss of
following requirements (a.), (b.), (c.) and (d.): coverage; or
a. The Employee or Dependent was covered under an- 6. For eligible Dependents who have lost or will lose their
other employer health benefit plan at the time he was coverage under the Healthy Families Program as a result
offered enrollment under this Plan; of exceeding the program’s income or age limits and who
request enrollment within 31 days after notification of this
b. The Employee or Dependent certified, at the time of loss of coverage; or
the initial enrollment, that coverage under another
employer health benefit plan was the reason for de- 7. For eligible Employees who decline coverage during the
clining enrollment provided that, if he was covered initial enrollment period and subsequently acquire De-
under another employer health plan, he was given the pendents through marriage, establishment of domestic
opportunity to make the certification required and partnership, birth, or placement for adoption, and who en-
was notified that failure to do so could result in later roll for coverage for themselves and their Dependents
treatment as a Late Enrollee; within 31 days from the date of marriage, establishment
of domestic partnership, birth, or placement for adoption.
c. The Employee or Dependent has lost or will lose
Medical Group — an organization of Physicians who are
coverage under another employer health benefit plan
generally located in the same facility and provide Benefits to
as a result of termination of his employment or of an
Members. For all Mental Health and substance abuse Ser-
individual through whom he was covered as a De-
vices, this definition includes the MHSA.
pendent, change in his employment status or of an
individual through whom he was covered as a De- Medical Necessity (Medically Necessary) —
pendent, termination of the other plan’s coverage,
1. Benefits are provided only for Services which are Medi-
exhaustion of COBRA continuation coverage, cessa-
tion of an employer’s contribution toward his cover-
age, death of an individual through whom he was 2. services which are Medically Necessary include only
covered as a Dependent, or legal separation, divorce, those which have been established as safe and effective
or termination of a domestic partnership; and and are furnished in accordance with generally accepted
professional standards to treat an illness, injury, or medi-
d. The Employee or Dependent requests enrollment cal condition, and which, as determined by Blue Shield,
within 31 days after termination of coverage or em- are:
ployer contribution toward coverage provided under
another employer health benefit plan; or a. consistent with Blue Shield medical policy; and,
2. The Employer offers multiple health benefit plans and the b. consistent with the symptoms or diagnosis; and,
eligible Employee elects this Plan during an Open En-
rollment Period; or c. not furnished primarily for the convenience of the
patient, the attending Physician or other provider;
3. A court has ordered that coverage be provided for a and,
spouse or Domestic Partner or minor child under a cov-
ered Employee's health benefit Plan. The health Plan d. furnished at the most appropriate level which can be
shall enroll a Dependent child within 31 days of presenta- provided safely and effectively to the patient.
tion of a court order by the district attorney, or upon pres-
3. If there are two or more Medically Necessary services
entation of a court order or request by a custodial party,
that may be provided for the illness, injury or medical
as described in Section 3751.5 of the Family Code; or
condition, Blue Shield will provide benefits based on the
4. For eligible Employees or Dependents who fail to elect most cost-effective service.
coverage in this Plan during their initial enrollment pe-
4. Hospital Inpatient Services which are Medically Neces-
riod, the Plan cannot produce a written statement from
sary include only those Services which satisfy the above
the Employer stating that prior to declining coverage, he
requirements, require the acute bed-patient (overnight)
or the individual through whom he was covered as a De-
setting, and which could not have been provided in a
pendent, was provided with and signed acknowledgment
Physician’s office, the Outpatient department of a Hospi- Partial Hospitalization/Day Treatment Program — a treat-
tal, or in another lesser facility without adversely affect- ment program that may be free-standing or Hospital-based and
ing the patient’s condition or the quality of medical care provides Services at least 5 hours per day and at least 4 days
rendered. per week. Patients may be admitted directly to this level of
care, or transferred from acute Inpatient care following acute
Inpatient services which are not Medically Necessary in-
Participating Hospice or Participating Hospice Agency —
a. for diagnostic studies that could have been provided an entity which: 1) provides Hospice Services to Terminally
on an Outpatient basis; Ill Members and holds a license, currently in effect, as a Hos-
b. for medical observation or evaluation; pice pursuant to Health and Safety Code Section 1747, or a
home health agency licensed pursuant to Health and Safety
c. for personal comfort; Code Sections 1726 and 1747.1 which has Medicare certifica-
tion and 2) has either contracted with Blue Shield of Califor-
d. in a pain management center to treat or cure chronic nia or has received prior approval from Blue Shield of Cali-
pain; or fornia to provide Hospice Service Benefits pursuant to the
e. for Inpatient rehabilitation that can be provided on California Health and Safety Code Section 1368.2.
an Outpatient basis. Personal Physician — a general practitioner, board-certified
5. Blue Shield reserves the right to review all services to or eligible family practitioner, internist, obstetri-
determine whether they are Medically Necessary. cian/gynecologist, or pediatrician who has contracted with the
Plan as a Personal Physician to provide primary care to Mem-
Member — either a Subscriber or Dependent. bers and to refer, authorize, supervise and coordinate the pro-
vision of all Benefits to Members in accordance with the con-
Mental Health Services — see definition for Psychiatric
Personal Physician Service Area — that geographic area
Mental Health Service Administrator (MHSA) — Blue
served by your Personal Physician’s Medical Group or IPA.
Shield of California has contracted with the Plan’s MHSA.
The MHSA is a specialized health care service plan licensed Physical Therapy — treatment provided by a Physician or
by the California Department of Managed Health Care, and under the direction of a Physician when provided by a regis-
will underwrite and deliver Blue Shield’s Mental Health and tered physical therapist, certified occupational therapist or
substance abuse Services through a unique network of MHSA licensed doctor of podiatric medicine. Treatment utilizes
Participating Providers. physical agents and therapeutic procedures, such as ultra-
sound, heat, range of motion testing, and massage, to improve
MHSA Participating Provider — a provider who has an
a patient’s musculoskeletal, neuromuscular and respiratory sys-
agreement in effect with the MHSA for the provision of Men-
tal Health and substance abuse Services.
Physician — an individual licensed and authorized to engage
Occupational Therapy — treatment under the direction of a
in the practice of medicine or osteopathic medicine.
Physician and provided by a certified occupational therapist,
utilizing arts, crafts, or specific training in daily living skills, Plan — the Blue Shield Access+ HMO Health Plan and/or
to improve and maintain a patient’s ability to function. Blue Shield of California.
Open Enrollment Period — that period of time set forth in Plan Hospital — a Hospital licensed under applicable state
the Contract during which eligible individuals and their De- law contracting specifically with Blue Shield to provide Bene-
pendents may transfer from another health benefit plan spon- fits to Members under the Plan.
sored by the Employer to the Blue Shield Access+ HMO Plan.
Plan Non-Physician Health Care Practitioner – a health
Orthosis (Orthotics) — an orthopedic appliance or apparatus care professional who is not a Physician and has an agreement
used to support, align, prevent, or correct deformities, or to with one of the contracted IPAs, Medical Groups, Plan Hospi-
improve the function of movable body parts. tals or Blue Shield to provide Covered Services to Members
when referred by a Personal Physician. For all Mental Health
Out-of-Area Follow-up Care — non-emergent Medically
and substance abuse Services, this definition includes MHSA
Necessary out-of-area Services to evaluate the Member’s pro-
gress after an initial Emergency or Urgent Service.
Plan Provider — a provider who has an agreement with Blue
Outpatient — an individual receiving Services under the
Shield to provide Plan Benefits to Members and an MHSA
direction of a Plan Provider, but not as an Inpatient.
Outpatient Facility — a licensed facility, not a Physician's
Plan Service Area — that geographic area served by the
office, or a Hospital that provides medical and/or surgical
Services on an Outpatient basis.
Plan Specialist — a Physician other than a Personal Physi- a. As a result of the mental disorder the child has sub-
cian, psychologist, licensed clinical social worker, or licensed stantial impairment in at least 2 of the following ar-
marriage and family therapist who has an agreement with Blue eas: self-care, school functioning, family relation-
Shield to provide Covered Services to Members either accord- ships, or ability to function in the community; and ei-
ing to an authorized referral by a Personal Physician, or ac- ther of the following has occurred: the child is at risk
cording to the Access+ Specialist program, or for OB/GYN of removal from home or has already been removed
Physician Services. For all Mental Health and substance from the home or the mental disorder and impair-
abuse Services, this definition includes MHSA Participating ments have been present for more than 6 months or
Providers. are likely to continue for more than 1 year without
Prosthesis (Prosthetics) — an artificial part, appliance, or
device used to replace a missing part of the body. b. The child displays one of the following: psychotic
Psychiatric Care (Mental Health Care Services) — psy- features, risk of suicide, or risk of violence due to a
choanalysis, psychotherapy, counseling, medical management, mental disorder.
or other services provided by a psychiatrist, psychologist, Services — includes Medically Necessary health care services
licensed clinical social worker, or licensed marriage and fam- and Medically Necessary supplies furnished incident to those
ily therapist, for diagnosis or treatment of a mental or emo- services.
tional disorder, or the mental or emotional problems associ-
ated with an illness, injury or any other condition. Severe Mental Illnesses — conditions with the following
diagnoses: schizophrenia, schizo affective disorder, bipolar
Reconstructive Surgery — surgery to correct or repair ab- disorder (manic depressive illness), major depressive disor-
normal structures of the body caused by congenital defects, ders, panic disorder, obsessive-compulsive disorder, pervasive
developmental abnormalities, trauma, infection, tumors, or developmental disorder or autism, anorexia nervosa, bulimia
disease to do either of the following: 1) to improve function, nervosa.
or 2) to create a normal appearance to the extent possible.
Skilled Nursing Facility — a facility with a valid license
Rehabilitation — Inpatient or Outpatient care furnished pri- issued by the California Department of Health Services as a
marily to restore an individual’s ability to function as normally “Skilled Nursing Facility” or any similar institution licensed
as possible after a disabling illness or injury. Rehabilitation under the laws of any other state, territory, or foreign country.
services may consist of Physical Therapy, Occupational Ther-
apy, and/or Respiratory Therapy and are provided with the Special Food Products — a food product which is both of
expectation that the patient has restorative potential. Benefits the following:
for Speech Therapy are described in Speech Therapy Benefits 1. Prescribed by a Physician or nurse practitioner for the
in the Plan Benefits section. Rehabilitation Services will be treatment of phenylketonuria (PKU) and is consistent
provided for as long as continued treatment is Medically Nec- with the recommendations and best practices of qualified
essary pursuant to the treatment plan. health professionals with expertise germane to, and ex-
Residential Care — services provided in a facility or a free- perience in the treatment and care of, phenylketonuria
standing residential treatment center that provides over- (PKU). It does not include a food that is naturally low in
night/extended-stay services for Members who do not qualify protein, but may include a food product that is specially
for Acute Care or Skilled Nursing Services. formulated to have less than one gram of protein per serv-
Respiratory Therapy — treatment, under the direction of a
Physician and provided by a certified respiratory therapist, to 2. Used in place of normal food products, such as grocery
preserve or improve a patient’s pulmonary function. store foods, used by the general population.
Serious Emotional Disturbances of a Child — refers to Speech Therapy — treatment under the direction of a Physi-
individuals who are minors under the age of 18 years who: cian and provided by a licensed speech pathologist or speech
therapist, to improve or retrain a patient’s vocal skills which
1. have one or more mental disorders in the most recent have been impaired by diagnosed illness or injury.
edition of the Diagnostic and Statistical Manual of Men-
tal Disorders (other than a primary substance use disorder Subacute Care — skilled nursing or skilled rehabilitation
or developmental disorder), that results in behavior inap- provided in a Hospital or Skilled Nursing Facility to patients
propriate for the child’s age according to expected devel- who require skilled care such as nursing services, Physical,
opmental norms, and Occupational or Speech Therapy, a coordinated program of
multiple therapies or who have medical needs that require
2. meet the criteria in paragraph (2) of subdivision (a) of daily registered nurse monitoring. A facility which is primar-
Section 5600.3 of the Welfare and Institutions Code. ily a rest home, convalescent facility, or home for the aged is
This section states that members of this population shall not included.
meet one or more of the following criteria:
Subscriber — an individual who satisfies the eligibility re- 2. in the case of a Dependent, a disability which prevents
quirements of the Contract, and who is enrolled and accepted the individual from engaging with normal or reasonable
by the Plan as a Subscriber, and has maintained Plan member- continuity in the individual's customary activities or in
ship in accord with this Contract. those in which the individual otherwise reasonably might
be expected to engage, in view of the individual's station
Total Disability —
in life and physical and mental capacity.
1. in the case of an Employee or Member otherwise eligible
Urgent Services — those Covered Services rendered outside
for coverage as an Employee, a disability which prevents
of the Personal Physician Service Area (other than Emergency
the individual from working with reasonable continuity in
Services) which are Medically Necessary to prevent serious
the individual’s customary employment or in any other
deterioration of a Member’s health resulting from unforeseen
employment in which the individual reasonably might be
illness, injury or complications of an existing medical condi-
expected to engage, in view of the individual's station in
tion, for which treatment can not reasonably be delayed until
life and physical and mental capacity.
the Member returns to the Personal Physician Service Area.
This combined Evidence of Coverage and Disclosure Form should be retained for your future reference as a Member of the
Blue Shield Access + HMO Plan.
Should you have any questions, please call the Blue Shield of California Member Services Department at the number pro-
vided on the last page of this booklet.
Blue Shield of California
50 Beale Street
San Francisco, CA 94105
Supplement A — Outpatient Prescription Drugs
Summary of Benefits
Member Contract Year Deductible
Brand Name Drug Deductible Responsibility
Per Member $0
There is no Brand Name Drug deductible requirement.
Benefit Member Copayment
Formulary Generic Drugs $5 Not covered
Formulary Brand Name Drugs $20 Not covered
Non-Formulary Brand Name Drugs $35 Not covered
Home Self-Administered Injectables, including any combination kit or pack- 20% of the Blue Not covered
age containing both oral and Home Self-Administered Injectable Drugs Shield negotiated
rate, up to a maxi-
mum of $100 for
Mail Service Formulary Generic Drugs $10 Not covered
Mail Service Formulary Brand Name Drugs $40 Not covered
Mail Service Non-Formulary Brand Name Drugs $70 Not covered
Mail Service Home Self-Administered Injectables, including any combina- Not covered Not covered
tion kit or package containing both oral and Home Self-Administered In-
Drugs obtained at a Non-Participating Pharmacy are not covered, unless Medically Necessary for a covered emergency, includ-
ing Drugs for emergency contraception. See the Obtaining Outpatient Prescription Drugs at a Non-Participating Pharmacy section
This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government
for Medicare Part D (also called creditable coverage). Because this plan’s 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 have a subsequent
break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Part D
Important: If you are a Member of this Plan and are a retiree or dependent of a retiree, and are entitled to Medicare Part A
and/or enrolled in Medicare Part B, this Supplement A and Supplement A1 describe the Enhanced Drug Benefit of your
Medicare Part D coverage. These two documents combine to describe your group prescription drug plan.
Outpatient Prescription Drug Benefits for the administration of Insulin as Medically Necessary, (4)
diabetic testing supplies (including lancets, lancet puncture
In addition to the benefits found in your Blue Shield Evidence
devices, and blood and urine testing strips and test tablets), (5)
of Coverage and Disclosure Form, your Plan also provides
oral contraceptives and diaphragms, (6) smoking cessation
coverage for Outpatient Prescription Drugs described in this
supplement. The following Prescription Drug Benefit is sepa- Drugs which require a prescription – coverage limited to one
rate from the HMO Health Plan coverage. The Contract Year 12-week course of treatment per lifetime, (7) inhalers and
Maximum Copayments and the Coordination of Benefits pro- inhaler spacers for the management and treatment of asthma.
visions do not apply to this Outpatient Prescription Drug Note: No prescription is necessary to purchase the items
Benefit; however, the general provisions and exclusions of the shown in (2), (3) and (4) above; however, in order to be cov-
HMO Health Plan contract shall apply. ered these items must be ordered by your Physician.
Benefits are provided for Outpatient Prescription Drugs which Formulary — a comprehensive list of Drugs maintained by Blue
meet all of the requirements specified in this supplement, are Shield’s Pharmacy and Therapeutics Committee for use under the
prescribed by the Member’s Personal Physician and are ob- Blue Shield Prescription Drug Program, which is designed to
tained from a Participating Pharmacy. Drug coverage is based assist Physicians in prescribing Drugs that are Medically Neces-
on the use of the Blue Shield’s Outpatient Drug Formulary, sary and cost effective. The Formulary is updated periodically. If
which is updated on an ongoing basis by Blue Shield’s Phar- not otherwise excluded, the Formulary includes all Generic Drugs.
macy and Therapeutics Committee. Non-Formulary Drugs
may be covered subject to higher Copayments. Selected Drugs Generic Drugs — Drugs that (1) are approved by the Food and
and Drug dosages and most Home Self-Administered In- Drug Administration (FDA) as a therapeutic equivalent to the
jectables require prior authorization by Blue Shield for Medi- Brand Name Drug, (2) contain the same active ingredient as the
cal Necessity, appropriateness of therapy or when effective, Brand Name Drug, and (3) cost less than the Brand Name Drug
lower cost alternatives are available (the more costly alterna- equivalent.
tive will be authorized when Medically Necessary). Your Phy-
Home Self-Administered Injectables — Home Self-
sician may request prior authorization from Blue Shield.
Administered Injectable medications are defined as those Drugs
Coverage for selected Drugs may be limited to a specific which are Medically Necessary, administered more often than
quantity as described in “Limitation on Quantity of Drugs that once a month by patient or family member, administered subcuta-
May Be Obtained Per Prescription or Refill”. neously or intramuscularly, deemed safe for self-administration as
determined by Blue Shield’s Pharmacy and Therapeutics Com-
Outpatient Drug Formulary mittee, prior authorized by Blue Shield, and obtained from a Blue
Medications are selected for inclusion in Blue Shield’s Outpa- Shield Specialty Pharmacy. Intravenous (IV) medications (i.e.
tient Drug Formulary based on safety, efficacy, FDA bio- those medications administered directly into a vein) are not con-
equivalency data and then cost. New drugs and clinical data sidered Home Self-Administered Injectable Drugs. Home Self-
are reviewed regularly to update the Formulary. Drugs con- Administered Injectables are listed in the Blue Shield’s Outpatient
sidered for inclusion or exclusion from the Formulary are re- Drug Formulary.
viewed by Blue Shield’s Pharmacy and Therapeutics Commit-
Non-Formulary Drugs — Drugs determined by the Blue
tee during scheduled meetings four times a year.
Shield’s Pharmacy and Therapeutics Committee as being duplica-
Members may call Blue Shield Member Services at the num- tive or as having preferred Formulary Drug alternatives available.
ber listed on their Blue Shield Identification Card to inquire if Benefits may be provided for Non-Formulary Drugs and are al-
a specific drug is included in the Formulary. Member Ser- ways subject to the Non-Formulary Copayment.
vices can also provide Members with a printed copy of the
Formulary. Members may also access the Formulary through Non-Participating Pharmacy — a pharmacy which does not
the Blue Shield of California web site at participate in the Blue Shield Pharmacy Network.
http://www.blueshieldca.com. Participating Pharmacy — a pharmacy which participates in the
Benefits may be provided for Non-Formulary Drugs subject to Blue Shield Pharmacy Network. These Participating Pharmacies
higher Copayments. have agreed to a contracted rate for covered prescriptions for Blue
Shield Members. Note: The Mail Service Pharmacy is a Par-
Definitions ticipating Pharmacy.
Brand Name Drugs — FDA approved Drugs under patent to To select a Participating Pharmacy, you may go to
the original manufacturer and only available under the original http://www.blueshieldca.com or call the toll-free Member Services
manufacturer's branded name. number on your Blue Shield Identification Card.
Drugs — (1) Drugs which are approved by the Food and Specialty Pharmacy Network – select Participating Pharmacies
Drug Administration (FDA), requiring a prescription either by contracted by Blue Shield to provide covered Home Self-
Federal or California law, (2) Insulin, and disposable hypo- Administered Injectables. These pharmacies offer 24-hour clinical
dermic Insulin needles and syringes, (3) pen delivery systems
services and provide prompt home delivery of Home Self- Obtaining Outpatient Prescription Drugs at a Non-
Administered Injectables. Participating Pharmacy
To select a Specialty Pharmacy, you may go to Drugs obtained at a Non-Participating Pharmacy are not cov-
http://www.blueshieldca.com or call the toll-free Member ered, unless Medically Necessary for a covered emergency,
Services number on your Blue Shield Identification Card. including Drugs for emergency contraception.
Obtaining Outpatient Prescription Drugs at a Reimbursement for covered emergency claims will be based
Participating Pharmacy upon the purchase price of the covered prescription Drug(s)
less any applicable Copayment(s). Claims must be received
To obtain Drugs at a Participating Pharmacy, the Member within 1 year of the date of service to be considered for pay-
must present his Blue Shield Identification Card. Note: Ex- ment. Claim forms are available upon request from the Blue
cept for covered emergencies, claims for Drugs obtained Shield Service Center. Submit a completed Prescription Drug
without using the Blue Shield Identification Card will be de- Claim form noting “Emergency Request” on the form, to Blue
nied. Shield Pharmacy Services, P.O. Box 7168, San Francisco, CA
Benefits are provided for Home Self-Administered Injectables 94120.
only when obtained from a Blue Shield Specialty Pharmacy,
Obtaining Outpatient Prescription Drugs Through
except in the case of an emergency. In the event of an emer-
the Mail Service Prescription Drug Program
gency, covered Home Self-Administered Injectables that are
needed immediately may be obtained from any Participating For the Member’s convenience, when Drugs have been
Pharmacy, or, if necessary from a Non-Participating Phar- prescribed for a chronic condition and the Member’s medi-
macy. cation dosage has been stabilized, he may obtain the Drug
through Blue Shield’s Mail Service Prescription Drug Pro-
The Member is responsible for paying the applicable Copay-
gram. Prior to using this Mail Service Program, the Member
ment for each new and refill prescription Drug. The pharma-
must have received the same medication and dosage through
cist will collect from the Member the applicable Copayment at
the Blue Shield pharmacy network for at least two months.
the time the Drugs are obtained.
The Member should submit the applicable Mail Service Co-
For diabetic supplies (including disposable Insulin needles payment, an order form and his Blue Shield Member number
and syringes), diaphragms and smoking cessation therapy to the address indicated on the mail order envelope. Members
Drugs, the Formulary Brand Name Copayment applies. should allow 14 days to receive the Drug. The Member’s
Physician must indicate a prescription quantity which is equal
If the Participating Pharmacy contracted rate charged by the
to the amount to be dispensed. Home Self-Administered In-
Participating Pharmacy is less than or equal to the Member's
jectables, except for Insulin, are not available through the
Copayment, the Member will only be required to pay the Par-
Mail Service Prescription Drug Program.
ticipating Pharmacy’s contracted rate.
The Member is responsible for the applicable Mail Service
If this Outpatient Prescription Drug Benefit has a Brand Name
Prescription Drug Copayment for each new or refill prescrip-
Drug Deductible, you are responsible for payment of 100% of
the Participating Pharmacy contracted rate for the Drug to the
Blue Shield Participating Pharmacy at the time the Drug is For diabetic supplies (including disposable Insulin needles
obtained, until the Brand Name Drug Deductible is satisfied. and syringes), the Formulary Brand Name Copayment applies.
If the Member requests a Brand Name Drug when a Generic If the Participating Pharmacy contracted rate is less than or
Drug equivalent is available, and the Brand Name Drug De- equal to the Member's Copayment, the Member will only be
ductible has been satisfied (when applicable), the Member is required to pay the Participating Pharmacy’s contracted rate.
responsible for paying the difference between the Participating
If this Outpatient Prescription Drug Benefit has a Brand Name
Pharmacy contracted rate for the Brand Name Drug and its
Deductible, you are responsible for payment of 100% of the
Generic Drug equivalent, as well as the applicable Generic
Participating Pharmacy contracted rate for the Brand Name
Drug to the Mail Service Pharmacy prior to your prescription
If the prescription specifies a Brand Name Drug and the pre- being sent to you. To obtain the Participating Pharmacy con-
scribing Physician has written “Dispense As Written” or “Do tracted rate amount, please contact the Mail Service Pharmacy
Not Substitute” on the prescription, or if Generic Drug at 1-866-346-7200. The TTY telephone number is 1-866-346-
equivalent is not available, the Member is responsible for pay- 7197.
ing the applicable Brand Name Drug Copayment.
If the Member requests a Mail Service Brand Name Drug
when a Mail Service Generic Drug is available, and the Brand
Name Drug Deductible has been satisfied (when applicable),
the Member is responsible for the difference between the con-
tracted rate for the Mail Service Brand Name Drug and its
Mail Service Generic Drug equivalent, as well as the applica- tions of your Evidence of Coverage and Disclo-
ble Mail Service Generic Drug Copayment. sure Form);
If the prescription specifies a Mail Service Brand Name Drug
and the prescribing Physician has written “Dispense As Writ-
3. Take home drugs received from a Hospital,
ten” or “Do Not Substitute” on the prescription, or if a Mail convalescent home, Skilled Nursing Facility, or
Service Generic Drug equivalent is not available, the Member similar facility (see the Hospital Benefits (Fa-
is responsible for paying the applicable Mail Service Brand cility Services) and Skilled Nursing Facility
Name Drug Copayment. Benefits sections of your Evidence of Coverage
Limitation on Quantity of Drugs that May and Disclosure Form);
Be Obtained Per Prescription or Refill 4. Except as specifically listed as covered under
1. Outpatient Prescription Drugs are limited to a this Outpatient Prescription Drugs Supplement,
quantity not to exceed a 30-day supply. Some drugs which can be obtained without a pre-
prescriptions are limited to a maximum allow- scription or for which there is a non-
able quantity based on Medical Necessity and prescription drug that is the identical chemical
appropriateness of therapy as determined by equivalent (i.e., same active ingredient and dos-
Blue Shield’s Pharmacy and Therapeutics age) to a prescription drug;
Committee. 5. Drugs for which the Member is not legally ob-
2. Mail Service Prescription Drugs are limited to a ligated to pay, or for which no charge is made;
quantity not to exceed a 90-day supply. If the 6. Drugs that are considered to be experimental or
Member’s Physician indicates a prescription investigational;
quantity of less than a 90-day supply, that
amount will be dispensed, and refill authoriza- 7. Medical devices or supplies, except as specifi-
tions cannot be combined to reach a 90-day cally listed as covered herein (see the Durable
supply. Medical Equipment Benefits, Orthotics Bene-
fits, and Prosthetic Appliances Benefits sec-
3. Prescriptions may be refilled at a frequency that tions of your Evidence of Coverage and Disclo-
is considered to be Medically Necessary. sure Form);
Exclusions 8. Blood or blood products (see the Hospital
No Benefits are provided under the Outpatient Pre- Benefits (Facility Services) section of your
scription Drugs Benefit for the following (please Evidence of Coverage and Disclosure Form);
note, certain services excluded below may be cov- 9. Drugs when prescribed for cosmetic purposes,
ered under other benefits/portions of your Evidence including but not limited to drugs used to retard
of Coverage and Disclosure Form – you should re- or reverse the effects of skin aging or to treat
fer to the applicable section to determine if drugs hair loss;
are covered under that Benefit):
10. Dietary or Nutritional Products (see the Home
1. Drugs obtained from a Non-Participating Health Care Benefits, Home Infusion/Home In-
Pharmacy, except for Emergency coverage, jectable Therapy Benefits, and PKU Related
Drugs for emergency contraception, and Drugs Formulas and Special Food Products Benefits
obtained outside of California which are related sections of your Evidence of Coverage and
to an urgently needed service and for which a Disclosure Form);
Participating Pharmacy was not reasonably ac-
11. Injectable drugs which are not self-
administered, and all injectable drugs for the
2. Any drug provided or administered while the treatment of infertility. Other injectable medica-
Member is an Inpatient, or in a Physician’s of- tions may be covered under the Home Health
fice (see the Professional (Physician) Benefits Care Benefits, Home Infusion/Home Injectable
and Hospital Benefits (Facility Services) sec- Therapy Benefits, Hospice Program Benefits,
and Family Planning Benefits sections of the 16. Replacement of lost, stolen or destroyed pre-
health plan; scription Drugs;
12. Appetite suppressants or drugs for body weight 17. Pharmaceuticals that are reasonable and neces-
reduction except when Medically Necessary for sary for the palliation and management of Ter-
the treatment of morbid obesity. In such cases minal Illness and related conditions if they are
the drug will be subject to prior authorization provided to a Member enrolled in a Hospice
from Blue Shield; Program through a Participating Hospice
13. Drugs when prescribed for smoking cessation
purposes (over the counter or by prescription), 18. Drugs prescribed for treatment of dental condi-
except to the extent that smoking cessation pre- tions. This exclusion shall not apply to antibi-
scription Drugs are specifically listed as cov- otics prescribed to treat infection nor to medica-
ered under the “Drug” definition in this benefit tions prescribed to treat pain;
description; 19. Immunizations and vaccinations by any mode
14. Contraceptive devices (except diaphragms), of administration (oral, injection or otherwise)
injections and implants; solely for the purpose of travel.
15. Compounded medications if: (1) there is a See the Grievance Process portion of your Evi-
medically appropriate Formulary alternative, or, dence of Coverage and Disclosure Form for infor-
(2) there are no FDA-approved indications. mation on filing a grievance, your right to seek as-
Compounded medications that do not include at sistance from the Department of Managed Health
least one Drug, as defined, are not covered; Care, and your rights to independent medical re-
Supplement A1 —
Blue Shield of California Medicare Rx Plan
This Supplement A1 describes the Medicare Part D group prescription drug plan, called the Blue
Shield of California Medicare Rx Plan.1 This supplement is only applicable to retirees or dependents
of retirees enrolled in a Blue Shield group retiree plan, and who are eligible and accepted for en-
rollment in Medicare Part D by the Centers for Medicare & Medicaid Services (CMS). Any individ-
ual who is not eligible for Medicare Part D, or who enrolls in a Medicare Part D plan on an individ-
ual basis, is not eligible for coverage under this group Medicare prescription drug plan.
This Supplement A1 replaces (in large part) and supplements the prescription drug benefits described in
your Evidence of Coverage and Disclosure Form and Supplement A – Outpatient Prescription Drugs
(“Supplement A”). Your former employer or Blue Shield will coordinate your enrollment in Medicare Part
D on a group enrollment basis in order for you to receive coverage under this group Medicare prescription
You may decide to opt out of this Blue Shield of California Medicare Rx Plan by contacting your former
employer or Blue Shield of California Medicare Rx Plan Member Services at the number listed at the end
of this supplement. However, if you opt out of this coverage, or if you enroll individually in another Medi-
care Part D plan while enrolled in this Blue Shield of California Medicare Rx Plan, you and your enrolled
dependents may lose all coverage offered by your former employer, including medical benefits.
Blue Shield of California Medicare Rx Plan is a Medicare-approved Prescription Drug Plan for
employer groups. The Plan is open to all Medicare beneficiaries who reside in the Plan’s service
area, are entitled to Part A or enrolled in Part B, and meet their employer group’s eligibility criteria.
Minimal copayments, restrictions and limitations apply to some services. Members must continue to
pay Medicare Part B premiums if they are not otherwise paid for under Medicaid or by another
third-party. Members must use network pharmacies to access their prescription drug benefit, except
under non-routine circumstances when they cannot reasonably use network pharmacies. If members
obtain prescription drugs from non-network pharmacies in routine circumstances, neither Medicare
nor Blue Shield will be responsible for the costs. Blue Shield of California has a contract with the
Table of Contents
Definitions ................................................................................................................................................................................. 65
Identification card ...................................................................................................................................................................... 65
What drugs are covered by this Plan? ........................................................................................................................................ 65
Transition policy........................................................................................................................................................................ 66
Pharmacy network...................................................................................................................................................................... 68
Creditable coverage – What is the Medicare prescription drug plan late enrollment penalty? .................................................. 70
True out-of-pocket (TrOOP) and catastrophic coverage............................................................................................................ 70
Extra help for people with limited income and resources .......................................................................................................... 72
How to file a grievance .............................................................................................................................................................. 74
Complaints and appeals about your Part D prescription drug(s)................................................................................................ 75
Requests for Part D drugs or payments...................................................................................................................................... 75
Appeal Level 1: Appeal to the Plan ........................................................................................................................................... 78
Appeal Level 2: Independent Review Entity (IRE) ................................................................................................................... 80
Appeal Level 3: Administrative Law Judge (ALJ) .................................................................................................................... 80
Appeal Level 4: Medicare Appeals Council (MAC).................................................................................................................. 81
Appeal Level 5: Federal Court................................................................................................................................................... 81
Ending your membership ........................................................................................................................................................... 82
Definitions What is a formulary?
Network Pharmacy – has the same meaning as A formulary is a list of the drugs that we cover. We
“Participating Pharmacy” in Supplement A. will generally cover the drugs listed in our formu-
lary as long as the drug is medically necessary, the
Plan – means the Blue Shield of California Medi- prescription is filled at a Network Pharmacy and
care Rx Plan and any non-Medicare prescription other coverage rules are followed. For certain pre-
drug benefits that may be covered under your Evi- scription drugs, we have additional requirements
dence of Coverage and Disclosure Form and Sup- for coverage or limits on our coverage. These re-
plement A. quirements and limits are described later under the
Conflicts section “Utilization Management.”
To the extent there is a conflict between the terms The drugs on the formulary are selected by our Plan
of this Supplement A1 and any terms of the Evi- with the help of a team of health care providers.
dence of Coverage and Disclosure Form and Sup- Both brand name drugs and generic drugs are in-
plement A, the terms of this Supplement A1 shall cluded on the formulary. A generic drug is a pre-
govern. To the extent any provision of the Evi- scription drug that is approved by the Food and
dence of Coverage and Disclosure Form and Sup- Drug Administration (FDA) as having the same
plement A is inconsistent with Medicare law or active ingredient(s) as the brand name drug. Gener-
applicable CMS guidance, that provision shall be ally, generic drugs cost less than brand-name drugs.
superseded with the applicable requirements. Not all drugs are covered by our Plan. In some
cases, we have decided not to include a particular
drug on our formulary.
You will receive a Blue Shield of California Medi-
In certain situations, prescriptions filled at an out-
care Rx Plan identification card to present to your
of-network pharmacy may also be covered.
Network Pharmacy when you fill your prescrip-
tions. When you obtain prescriptions through the How do you find out what drugs are on the Blue
Plan’s network mail service pharmacy, include the Shield of California Medicare Part D formu-
member number listed on this card with your order. lary?
Please carry your Plan membership card with you Each year, we send you an updated Medicare Part
at all times and remember to show your card when D Plan formulary so you can find out what drugs
you get covered prescription drugs. If your mem- are on it. You can get updated information about
bership card is damaged, lost, or stolen, call Mem- the drugs our Blue Shield of California Medicare
ber Services right away and we will send you a new Rx Plan covers by visiting our website,
card. www.blueshieldca.com. You may also call Mem-
ber Services to find out if your Medicare Part D
What drugs are covered by this drug is on the formulary or to request an updated
Blue Shield of California Medicare Rx Plan Can the formulary change?
Outpatient Prescription Drug Benefit We may make certain changes to our formulary
Your Blue Shield of California Medicare Rx Plan during the year. Changes in the formulary may af-
benefits are based on the Medicare Part D approved fect which drugs are covered and how much you
formulary. Your prescription drug coverage may will pay when filling your prescription. The kinds
also include non-Medicare prescription drug bene- of formulary changes we may make include:
fits described in your Blue Shield of California • Adding or removing drugs from the formulary
Evidence of Coverage and Disclosure Form and
Supplement A. • Adding prior authorizations, quantity limits,
and/or step-therapy restrictions on a drug
• Moving a drug to a higher or lower cost-sharing prove, the Plan will reimburse you. If the ex-
tier ception isn’t approved, you may appeal our
Plan’s denial. See the sections on coverage de-
If we remove drugs from the formulary, or add
terminations and the appeal process to learn
prior authorizations, quantity limits and/or step
more about how to request an exception or an
therapy restrictions on a drug or move a drug to a
higher cost-sharing tier and you are taking the drug
affected by the change, you will be permitted to In some cases, we will contact you if you are taking
continue taking that drug at the same level of cost- a drug that isn’t on our formulary. We can give you
sharing for the remainder of the Plan year. How- the names of covered drugs that are also used to
ever, if a brand name drug is replaced with a new treat your condition so you can ask your doctor if
generic drug, or our formulary is changed as a re- any of these drugs are an option for your treatment.
sult of new information on a drug’s safety or effec- If you recently joined this Plan, you may be able to
tiveness, you may be affected by this change. get a temporary supply of a drug you were taking
We will notify you of the change at least 60 days when you joined our Plan if it is not on our formu-
before the date that the change becomes effective lary.
or provide you with a 60 day supply at the phar-
macy. This will give you an opportunity to work Transition policy
with your physician to switch to a different drug New members in our Plan may be taking drugs that
that we cover or request an exception. (If a drug is are not on our formulary, or that are subject to cer-
removed from our formulary because the drug has tain restrictions, such as prior authorization or step
been recalled from the pharmacies, we will not give therapy. Current members may also be affected by
60 days notice before removing the drug from the changes in our formulary from one year to the next.
formulary. Instead, we will remove the drug imme- Members should talk to their doctors to decide if
diately and notify members taking the drug about they should switch to a different drug that we cover
the change as soon as possible.) or request a formulary exception in order to get
What if your drug is not on the Blue Shield of coverage for the drug. See the “What is an excep-
California Medicare Rx Plan formulary? tion?” section to learn more about how to request
an exception. Please contact Member Services if
If your prescription is not listed on your copy of the
your drug is not on our formulary, is subject to cer-
formulary, you should first check our website,
tain restrictions (such as prior authorization or step
www.blueshieldca.com. In addition, you should
therapy) or it will no longer be on our formulary
contact Member Services to be sure it is not cov-
next year, and you need help switching to an ap-
propriate drug that we cover or you need to request
If Member Services confirms that we don’t cover a formulary exception.
your drug, you have two options:
During the period of time members are talking with
• You may ask your doctor if you can switch to their doctors to determine the right course of action,
another drug that is covered by us. If you would we may provide a temporary supply of the non-
like to give your doctor a list of covered drugs formulary drug if those members need a refill for
that are used to treat similar medical conditions, the drug during the first 90 days of new member-
please contact Member Services or go to our ship in our Plan. If you are a current enrollee af-
Blue Shield of California Medicare Rx Plan fected by a formulary change from one year to the
formulary on our website. next, we will provide a temporary supply of the
• You or your doctor may ask us to make an ex- non-formulary drug if you need a refill for the drug
ception (a type of coverage determination) to during the first 90 days of the new plan year.
cover your drug. If you pay out-of-pocket for When a member goes to a Network Pharmacy and
the drug and request an exception that we ap- we provide a temporary supply of a drug that is not
on our formulary, or that has coverage restrictions doctors and pharmacists developed these require-
or limits (but is otherwise considered a “Part D ments and limits for our Plan to help us to provide
drug”), we will cover a 30-day supply (unless the quality coverage to our members. Please consult
prescription is written for fewer days). your copy of our formulary or the formulary on our
website for more information about these require-
After we cover the temporary 30-day supply, we
ments and limits.
will generally not pay for these drugs as part of our
transition policy again. We will provide you with a The requirements for coverage or limits on certain
written notice after we cover your temporary sup- drugs are listed as follows:
ply. This notice will explain the steps you can take
• Prior Authorization: We require you to get
to request an exception and how to work with your
prior authorization (prior approval) for certain
doctor to decide if you should switch to an appro-
drugs. This means that your provider will need
priate drug we cover.
to contact us before you fill your prescription. If
If the new member is a resident of a long-term care we don’t get the necessary information to sat-
facility (like a nursing home), we will cover a tem- isfy the prior authorization, we may not cover
porary 34-day transition supply (unless the pre- the drug.
scription is written for fewer days). If necessary, we
• Quantity Limits: In some cases, we limit the
will cover more than one refill of these drugs dur-
amount of the drug that we will cover per pre-
ing the first 90 days a new member is enrolled in
scription or for a defined period of time. For
our Plan when the member is a resident of a long-
example, we will provide up to nine tablets per
term care facility. If the resident has been enrolled
month, per prescription for sumatriptan (Imi-
in our Plan for more than 90 days and needs a drug
that isn’t on our formulary or is subject to other re-
strictions such as step therapy or dosage limits, we • Step Therapy: In some cases, we require you
will cover a temporary 34-day emergency supply of to first try one drug to treat your medical condi-
that drug (unless the prescription is for fewer days) tion before we will cover another drug for that
while the new member pursues a formulary excep- condition. For example, if Drug A and Drug B
tion. both treat your medical condition, we may re-
quire your doctor to prescribe Drug A first. If
Blue Shield of California has a transition process to
Drug A does not work for you, then we will
provide coverage for individuals who are stabilized
cover Drug B.
on certain drug regimens and to ensure an appro-
priate transition process for members who have a • Generic Substitution: When there is a generic
change in treatment settings due to changes in level version of a brand name drug available, our
of care. Please note that our transition policy ap- Network Pharmacies will automatically give
plies only to those drugs that are “Part D drugs” you the generic version, unless your doctor has
and that are purchased at a Network Pharmacy. The told us that you must take the brand name drug
transition policy could not be used to purchase a and we have approved this request.
non-Part D drug or a drug out-of-network, unless You can find out if your drug is subject to these
the individual qualifies for out-of-network access. additional requirements or limits by looking in the
Drug management programs formulary, on our website or by calling Member
Services. If your drug is subject to one of these ad-
Utilization management ditional restrictions or limits and your physician
For certain prescription drugs, we have additional determines you are not able to meet the additional
requirements for coverage or limits on our cover- restriction or limit for medical necessity reasons,
age. These requirements and limits ensure that our you or your physician can request an exception
members use these drugs in the most effective way (which is a type of coverage determination). See
and also help us control drug plan costs. A team of
the “What is an exception?” section for more in- If you are selected to join a medication therapy
formation. management program, we will send you informa-
tion about the specific program, including informa-
Drug utilization review
tion about how to access the program.
We conduct drug utilization reviews for all of our
members to make sure that they are receiving safe Pharmacy network
and appropriate care. These reviews are especially
With few exceptions, you must use Network
important for members who have more than one
Pharmacies to get your prescription drugs cov-
doctor who prescribe their medications. We con-
duct drug utilization reviews each time you fill a
prescription and on a regular basis by reviewing our A Network Pharmacy is a pharmacy that has a con-
records. During these reviews, we look for medica- tract with us to provide your covered prescription
tion problems such as: drugs. The term “covered drugs” means all of the
outpatient prescription drugs that are covered by
• Possible medication errors;
our Plan. Covered drugs are listed in our formulary.
• Duplicate drugs that are unnecessary because
In most cases, your prescriptions are covered only
you are taking another drug to treat the same
if they are filled at one of our Network Pharmacies.
You are not required to always go to the same phar-
• Drugs that are inappropriate because of your macy to fill your prescription; you can go to any of
age or gender; our Network Pharmacies. However, if you switch
• Possible harmful interactions between drugs to a different Network Pharmacy than the one you
you are taking; have previously used, you must either have a new
prescription written by a doctor or have the previ-
• Drug allergies; ous pharmacy transfer the existing prescription to
• Drug dosage errors. the new pharmacy if any refills remain. To find a
Network Pharmacy in your area, please review your
If we identify a medication problem during our Blue Shield of California pharmacy directory. You
drug utilization review, we will work with your can also visit our website or call Member Services.
doctor to correct the problem.
You may pay less for your prescriptions at a pre-
Medication therapy management programs ferred Network Pharmacy. You may receive your
We offer medication therapy management pro- prescriptions at other Network Pharmacies, but you
grams at no additional cost for select members who may have to pay more for your prescriptions. Please
have multiple medical conditions, who are taking refer to your pharmacy directory or call Member
many prescription drugs, and who have high drug Services to locate a preferred Network Pharmacy.
costs. These programs were developed for us by a We will send you a complete Blue Shield pharmacy
team of pharmacists and doctors. We use these directory, which gives you a list of our Network
medication therapy management programs to help Pharmacies, at least every three years, and an up-
us provide better medication therapy management date of our pharmacy directory every year that we
for our members. For example, these programs will don’t send you a complete pharmacy directory. You
help us make sure that our members are using ap- can use it to find the Network Pharmacy closest to
propriate drugs to treat their medical conditions and you. If you don’t have the pharmacy directory, you
help us identify possible medication errors. can get a copy from Member Services. They can
We may contact members who qualify for these also give you the most up-to-date information
programs. If we contact you, we hope you will join about changes in this Plan’s Network Pharmacies,
so that we can help you manage your medications. which can change during the year. You can also
Remember, you do not need to pay anything extra find this information on our website,
to participate. www.blueshieldca.com.
What if a pharmacy is no longer a Network able to access these pharmacies under limited cir-
Pharmacy? cumstances (e.g., emergencies).
Sometimes a pharmacy may leave our Plan’s net- Blue Shield has Indian Health Service/Tribal/Urban
work. If this happens, you will have to get your Indian Health Program pharmacies in our network.
prescription filled at another Network Pharmacy. Please refer to your pharmacy directory to find an
Please refer to your Blue Shield of California I/T/U pharmacy in your area. For more informa-
pharmacy directory or call Member Services to find tion, please contact Member Services.
another Network Pharmacy in your area.
How does your enrollment in this Plan affect
Specialty pharmacies coverage for the drugs covered under Medicare
Part A or Part B?
Home infusion pharmacies
Your enrollment in this group Blue Shield of Cali-
Our Plan will cover home infusion therapy if: fornia Medicare Rx Plan does not affect Medicare
• Your prescription drug is on our Plan’s formu- coverage for drugs covered under Medicare Part A
lary or a formulary exception has been granted or Part B. If you meet Medicare’s coverage re-
for your prescription drug; quirements, your drug will still be covered under
Medicare Part A or Part B even though you are en-
• Your prescription drug is not otherwise covered
rolled in this Blue Shield of California Medicare
under our Plan’s medical benefit;
Rx Plan. In addition, if your drug is covered by
• Our Plan has approved your prescription for Medicare Part A or Part B, it cannot be covered by
home infusion therapy; and this Blue Shield of California Medicare Rx Plan
• Your prescription is written by an authorized even if you choose not to participate in Part A or
prescriber. Part B. Some drugs may be covered under Medi-
care Part B in some cases and through this Plan
Please refer to your pharmacy directory to find a (Medicare Part D) in other cases but never both at
home infusion pharmacy provider in your area. For the same time. In general, your pharmacist or pro-
more information, please contact Member Services. vider will determine whether to bill Medicare Part
Long-term care (LTC) pharmacies B or Blue Shield of California Medicare Rx Plan
for the drug in question.
Generally, residents of a long-term care facility
(like a nursing home) may get their prescription See your Medicare and You handbook for more
drugs through the facility’s LTC pharmacy or an- information about drugs that are covered by Medi-
other Network LTC Pharmacy. Please refer to your care Part A and B. The Medicare and You hand-
pharmacy directory to find out if your LTC phar- book can also be found on www.medicare.gov or
macy is part of our network. If it isn’t, or for more you can request a copy by calling 1-800-
information, contact Member Services. MEDICARE (1-800-633-4227). TTY users should
Blue Shield has a process in place to assist you
when you are in a long-term care (LTC) facility. If you have a Medigap (Medicare Supplement
See the “Transition Policy” section for more infor- Insurance) policy with prescription drug cover-
Indian Health Service/Tribal/Urban Indian If you currently have a Medigap policy that in-
Health Program (I/T/U) pharmacies cludes coverage for prescription drugs, you must
contact your Medigap issuer and tell them you have
Only Native Americans and Alaska Natives have
enrolled in this Blue Shield of California Medicare
access to Indian Health Service/Tribal/Urban In-
Rx Plan. If you decide to keep your current Medi-
dian Health Program (I/T/U) pharmacies through
gap policy, your Medigap issuer will remove the
our Plan’s Network Pharmacies. Others may be
prescription drug coverage portion of your Medi- about the late enrollment reconsideration process
gap policy and adjust your premium. and how to ask for such a review.
Each year (prior to November 15) your Medigap You won’t have to pay a late enrollment penalty
insurance company must send you a letter explain- if:
ing your options and whether the prescription drug • You had creditable prescription drug coverage
coverage you have is credible (whether it expects to (coverage that expects to pay, on average, at
pay, on average, at least as much as Medicare’s least as much as Medicare’s standard prescrip-
standard prescription drug coverage) and how the tion drug coverage);
removal of drug coverage from your Medigap pol-
icy will affect your premiums. If you didn’t get this • You had prescription drug coverage, but you
letter or can’t find it, you have the right to get a were not adequately informed that the coverage
copy from your Medigap insurance company. was not credible (as good as Medicare’s drug
Creditable coverage – What is the • Any period of time that you didn’t have credit-
Medicare prescription drug plan late able prescription drug coverage was less than
enrollment penalty? 63 continuous days;
If you don’t join a Medicare drug plan when you • You lived in an area affected by Hurricane
are first eligible, and/or you go without creditable Katrina at the time of the hurricane (August
prescription drug coverage (as good as Medicare’s) 2005) AND you signed up for a Medicare pre-
for a continuous period of 63 days or more, you scription drug plan by December 31, 2006,
may have to pay a late enrollment penalty when AND you stay in a Medicare prescription drug
you enroll in a plan later. The plan will let you plan;
know what the amount is and it will be added to
• You received or are receiving extra help AND
your monthly premium. This penalty amount
you enroll in a Medicare prescription drug plan
changes every year, and you will have to pay it as
by December 31, 2008, AND you stay in a
long as you have Medicare prescription drug cover-
Medicare prescription drug plan.
age. However, if you qualified for extra help in
2006, 2007, or 2008, you may not have to pay a True out-of-pocket (TrOOP) and
If you must pay a late enrollment penalty, your
The Blue Shield of California Medicare Rx Plan
penalty is calculated when you first join a Medicare
provides for catastrophic drug coverage once you
drug plan. To estimate your penalty, take 1% of the
have reached the True Out-of-Pocket (TrOOP) ex-
national base beneficiary premium for the year you
pense threshold. TrOOP expenses are the out-of-
join (in 2009, the national base beneficiary pre-
pocket costs of prescription drugs that you pay un-
mium is $30.36). Multiply it by the number of full
der Medicare Part D coverage.
months you were eligible to join a Medicare drug
plan but didn’t, and then round that amount to the When your annual TrOOP costs reach $4,350 in a
nearest ten cents. calendar year, you will qualify for catastrophic cov-
erage. During catastrophic coverage you will pay
This is your estimated penalty amount, which is
until the end of the calendar year:
added each month to your Medicare drug plan’s
premium for as long as you are in that plan. • Greater of $2.40 or 5% of Blue Shield’s con-
tracted rate for a 30- to 90-day supply of ge-
If you disagree with your late enrollment penalty,
neric drugs or drugs that are treated like generic
you may be eligible to have it reconsidered (re-
drugs on the Blue Shield of California Medi-
viewed). Call Member Services to find out more
care Rx Plan formulary.
• Greater of $6.00 or 5% of Blue Shield’s con- • Prescription drugs not covered by the Blue
tracted rate for a 30- to 90-day supply of all Shield of California Medicare Rx Plan;
other drugs on the Blue Shield of California
• Copayments for non-Medicare prescription
Medicare Rx Plan formulary.
drugs covered under your Blue Shield of Cali-
Prior to becoming eligible for catastrophic cover- fornia Evidence of Coverage and Disclosure
age, you will receive covered prescriptions at the Form and Supplement A;
copayments described in Supplement A. Once you
• Prescription drugs obtained at an out-of-
are eligible for catastrophic coverage, your copay-
Network Pharmacy when that purchase does
ments will be either the above-referenced amounts
not meet our requirements for out-of-network
or the copayments described in Supplement A,
whichever is less.
• Non-Part D drugs, including prescription drugs
How is your out-of-pocket cost covered by Part A or Part B and other drugs ex-
calculated? cluded from coverage by Medicare;
What type of prescription drug payments count Who can pay for your prescription drugs, and
toward your out-of-pocket costs? how do these payments apply to your out-of-
The following types of payments for prescription pocket costs?
drugs may count toward your out-of-pocket costs Except for your premium payments, any payments
and help you qualify for catastrophic coverage as you make for Part D drugs covered by us count to-
long as the drug you are paying for is a Part D drug ward your out-of-pocket costs and will help you
or transition drug, on the formulary (or if you get a qualify for catastrophic coverage. In addition, when
favorable decision on a coverage determination re- the following individuals or organizations pay your
quest, exception request or appeal), obtained at a costs for such drugs, these payments will count to-
Network Pharmacy (or you have an approved claim ward your out-of-pocket costs (and will help you
from an out-of-network pharmacy); and otherwise qualify for catastrophic coverage):
meets our coverage requirements:
• Family members or other individuals;
• Your annual deductible;
• Medicare programs that provide extra help with
• Your coinsurance or copayments ; prescription drug coverage; and
• Payments you made this year under another • Most charities or charitable organizations that
Medicare prescription plan prior to your en- pay cost-sharing on your behalf. Please note
rollment in our plan; that if the charity is established, run or con-
When you have spent a total of $4,350 for these trolled by your current or former employer or
items, you will reach the catastrophic coverage union, the payments usually will not count to-
level. ward your out-of-pocket costs.
What type of prescription drug payments will Payments made by the following don’t count to-
not count toward your out-of pocket costs? ward your out-of-pocket costs:
• Group health plans;
The amount you pay for your monthly premium
doesn’t count toward reaching the catastrophic • Insurance plans and government funded health
coverage level. In addition, the following types of programs (e.g., TRICARE, the VA, the Indian
payment for prescription drugs do not count to- Health Service, AIDS Drug Assistance Pro-
ward your out-of-pocket costs: grams); and
• Prescription drugs purchased outside the United • Third party arrangements with a legal obliga-
States and its territories; tion to pay for prescription costs (e.g., Workers’
If you have coverage from a third party such as - Total Out-Of-Pocket Costs That Count
those listed above that pays a part of or all of your Toward Catastrophic Coverage – the to-
out-of-pocket costs, you must let us know. tal amount you and/or others have spent on
We will be responsible for keeping track of your prescription drugs that count toward your
out-of-pocket cost amount and will let you know qualifying for catastrophic coverage. This
when you have qualified for catastrophic coverage. total includes the amounts spent for your
If you are in a coverage gap or deductible period deductible, copayments and coinsurance,
and have purchased a covered Part D drug at a and payments made on covered Part D
Network Pharmacy under a special price or dis- drugs after you reach the initial coverage
count card that is outside our Plan’s benefit, you limit. (This amount does not include pay-
may submit documentation and have it count to- ments made by your current or former em-
ward qualifying you for catastrophic coverage. In ployer/union, another insurance plan or pol-
addition, every month you purchase covered pre- icy, government funded health program or
scription drugs through us, you will get an Explana- other excluded parties.)
tion of Benefits that shows your out-of-pocket cost
Extra help for people with limited
amount to date.
income and resources
What is the Explanation of Benefits?
What extra help is available to help pay my plan
The Explanation of Benefits (EOB) is a document costs?
you will get for each month you use your Plan pre-
scription drug coverage. The EOB will tell you the Medicare provides “extra help” to pay prescription
total amount you have spent on your prescription drug costs for people who have limited income and
drugs and the total amount we have paid for your resources. Resources include your savings and
drugs. You will get your Explanation of Benefits in stocks, but not your home or car. If you qualify, you
the mail each month when you use the benefits that will get help paying for your Medicare drug plan’s
we provide. An Explanation of Benefits is also monthly premium, yearly deductible and prescrip-
available upon request. To get a copy, please con- tion copayments. If you qualify, this extra help will
tact Member Services. count toward your out-of-pocket costs.
What information is included in the Explana- Do you qualify for extra help?
tion of Benefits? People with limited income and resources may
Your Explanation of Benefits will contain the fol- qualify for extra help one of two ways. The amount
lowing information: of extra help you get will depend on your income
• A list of prescriptions you filled during the
month, as well as the amount paid for each pre- 1. You automatically qualify for extra help and
scription; don’t need to apply. If you have full coverage
from a state Medicaid program, get help from
• Information about how to request an exception Medicaid paying your Medicare premiums (be-
and appeal our coverage decisions; long to a Medicare Savings Program), or get
• A summary of your coverage this year, includ- Supplemental Security Income benefits, you
ing information about: automatically qualify for extra help and do not
have to apply for it. Medicare mails a letter to
- Annual Deductible – the amount paid be- people who automatically qualify for extra
fore you start getting prescription coverage. help.
- Amount Paid For Prescriptions – the 2. You apply and qualify. You may qualify if
amounts paid that count towards your initial your yearly income in 2008 is less than $15,600
coverage limit. (single with no dependents) or $21,000 (mar-
ried and living with your spouse), and your re- Mail:
sources are less than $11,990 (single) or
Blue Shield of California Medicare Rx Plan
$23,970 (married and living with your spouse).
PO Box 927
These resource amounts include $1,500 per
Woodland Hills, CA 91365
person for burial expenses. Resources include
your savings and stocks but not your home or
car. When we receive the evidence showing your co-
payment level, we will update our system or im-
If you think you may qualify, call Social Security at
plement other procedures so that you can pay the
1-800-772-1213, (TTY users should call 1-800-
correct copayment when you get your next pre-
325-0778) or visit www.socialsecurity.gov on the
scription at the pharmacy. Please be assured that if
web. You may also be able to apply at your State you overpay your copayment, we will reimburse
Medical Assistance (Medicaid) office. After you you. Of course, if the pharmacy hasn’t collected a
apply, you will get a letter in the mail letting you copayment from you and is carrying your copay-
know if you qualify and what you need to do next. ment as a debt owed by you, we may make the
The above income and resource amounts are for payment directly to the pharmacy. If a state paid on
2008 and will change in 2009. If you live in Alaska your behalf, we may make payment directly to the
or Hawaii, or pay at least half of the living ex- state. Please contact Member Services if you have
penses of dependent family members, income lim- questions at 1-888-239-6469 (TTY/TTD users call
its are higher. 1-888-239-6482).
How do costs change when you qualify for extra Important information about Medicare
help? prescription drug coverage
If you qualify for extra help, we will send you by Using all of your insurance coverage
mail an “Evidence of Coverage Rider for those
who Receive Extra Help Paying for their Prescrip- If you have additional prescription drug coverage
tion Drugs” that explains your costs as a member of besides our Plan, it is important that you use your
our Plan. If the amount of your extra help changes other coverage in combination with your coverage
during the year, we will also mail you an updated as a member of our Plan to pay your prescription
“Evidence of Coverage Rider for those who Re- drug expenses. This is called “coordination of
ceive Extra Help Paying for their Prescription benefits” because it involves coordinating all of the
Drugs.” drug benefits that are available to you. Using all of
the coverage you have helps keep the cost of health
What if you believe you have qualified for extra care more affordable for everyone.
help and you believe that you are paying an in-
correct copayment amount? Coordination of Benefits (COB) if you have
other prescription drug coverage
If you believe you have qualified for extra help and
you believe that you are paying an incorrect co- We will send you our Medicare Questionnaire for
payment amount when you get your prescription at Beneficiaries with Prescription Drug Coverage so
a pharmacy, our Plan has established a process that that we can know what other health and/or drug
will allow you to either request assistance in ob- coverage you have besides our Plan. Medicare re-
taining evidence of your proper copayment level, quires us to collect this information from you, so
or, if you already have the evidence, to provide this when you get the survey, please fill it out and send
evidence to us. it to us. If you have additional health and/or drug
coverage, you must provide that information to our
Please call Member Services at 1-888-239-6469 Plan. The information you provide helps us calcu-
(TTY/TDD: 1-888-239-6482). If it is determined late how much you and others have paid for your
that evidence is needed, you can mail or fax in your prescription drugs. In addition, if you lose or gain
additional health and/or prescription drug coverage, • We don’t forward your case to the Independent
please call Member Services to update your mem- Review Entity if we do not give you a decision
bership records. on time.
If you have one of these types of problems and
How to file a grievance
want to make a complaint, it is called “filing a
For Medicare Part D prescription drug cover- grievance.”
age only, the following grievance and appeals
Who may file a grievance
process replaces that set forth in Supplement A and
the Blue Shield Evidence of Coverage and Disclo- You or someone you name may file a grievance.
sure Form. It applies to any appeal or grievance The person you name would be your “representa-
under the group Blue Shield of California Medicare tive.” You may name a relative, friend, lawyer, ad-
Rx Plan. vocate, doctor, or anyone else to act for you. Other
persons may already be authorized by the court or
What is a grievance?
in accordance with state law to act for you. If you
A grievance is any complaint other than one that want someone to act for you who is not already au-
involves a request for an initial determination or an thorized by the court or under state law, then you
appeal. Grievances do not involve problems related and that person must sign and date a statement that
to approving or paying for Part D drugs. gives the person legal permission to be your repre-
If we will not pay or give you the Part D drugs you sentative. To learn how to name your representa-
want, you must follow the rules outlined in the sec- tive, you may call Member Services.
tion, “Complaints and appeals about your Part D Filing a grievance with our Plan
prescription drug benefits.”
If you have a complaint, you or your representative
What types of problems might lead to you filing may call Member Services at 1-888-239-6469
a grievance? (TTY/TDD: 1-888-239-6482) for complaints
• Problems with the service you receive from about Part D drugs. We will try to resolve your
Member Services. complaint over the phone. If you ask for a written
response, file a written grievance, or your com-
• If you feel that you are being encouraged to plaint is related to quality of care, we will respond
leave (disenroll from) our Plan. in writing to you. If we cannot resolve your com-
• If you disagree with our decision not to give plaint over the phone, we have a formal proce-
you a “fast” decision or a “fast” appeal. We dure to review your complaints.
discuss these fast decisions and appeals in more The Blue Shield of California Medicare Rx Plan
detail in the initial determination and appeals grievance process consists of two steps:
Step One: File a grievance
• We don’t give you a decision within the re-
quired timeframe. To begin the process, call a Member Services rep-
resentative within 60 days of the event or incident,
• We don’t give you required notices. and ask to file a grievance. You may also file a
• You believe our notices and other written mate- grievance in writing within 60 days of the event or
rials are hard to understand. incident by sending it to:
• Waiting too long for prescriptions to be filled. Blue Shield of California Medicare Rx Plan
Attn: Member Services Department
• Rude behavior by network pharmacists or other
PO Box 927
Woodland Hills, CA 91365-0927
We will let you know that we received the notice of For quality of care complaints, you may also
your concern within five days and will give you the complain to the Quality Improvement Organi-
name of the person who is working on it. We must zation (QIO)
address your grievance as quickly as your case re- You may complain about the quality of care re-
quires based on your health status, but no later than ceived under Medicare. You may complain to us
30 days after receiving your complaint. We may using the grievance process, to the Quality Im-
extend the timeframe by up to 14 days if you ask provement Organization (QIO), or both. If you file
for the extension, or if we justify a need for addi- with the QIO, we must help the QIO resolve the
tional information and the delay is in your best in- complaint. In California, the QIO is Health Ser-
terest. If we deny your grievance in whole or in vices Advisory Group, Inc. (HSAG).
part, our written decision will explain why we de-
nied it, and will tell you about any dispute resolu- You must write to HSAG to file a quality of care
tion options you may have. complaint. You can file your complaint with
HSAG at any time. If you file with HSAG, we must
Fast Grievances help them resolve the complaint.
In certain cases, you have the right to ask for a “fast You may contact the Health Services Advisory
grievance,” meaning we will answer your grievance Group, Inc. at:
within 24 hours. If you ask for a fast grievance be-
cause we decided not to give you a “fast decision” Health Services Advisory Group, Inc.
or “fast appeal” or because we asked for an exten- Attn: Beneficiary Protection
sion on our initial decision or fast appeal, we will 5201 W. Kennedy Boulevard Suite 900
forward your request to a Medical Director who Tampa, Florida 33609-1822
was not involved in our original decision. We may HSAG Phone: 1-800-841-1602
ask if you have additional information that was not TDD #: 1-800-881-5980
available at the time you requested a fast initial de- FAX: 1-866-800-8757
cision or fast appeal. Website: www.hsag.com/camedicare
The Medical Director will review your request and
decide if our original decision was appropriate. We Complaints and appeals about your
will send you a letter with our decision within 24 Part D prescription drug(s)
hours of your request for a fast grievance. This section explains how you ask for coverage of
Step Two: Grievance hearing your Part D drug(s) or payments in different situa-
tions. These types of requests and complaints are
If you are not satisfied with this resolution, you
discussed below. Other complaints that do not in-
may make a written request to the Blue Shield of
volve the types of requests or complaints discussed
California Medicare Rx Plan Appeals and Griev-
below are considered grievances. You would file a
ance Resolution Department for a grievance hear-
grievance if you have any type of problem with us
or one of our network providers that does not relate
Within 31 days of your written request, we will as- to coverage for Part D drugs. For more information
semble a panel to hear your case. You will be in- about grievances see the previous section.
vited to attend the hearing, which includes an unin-
volved physician and a representative from the Ap- Requests for Part D drugs or
peals and Grievance Resolution Department. You payments
may attend in person or by teleconference. After the
This section explains what you can do if you have
hearing, we will send you a final resolution letter.
problems getting the Part D Drugs you request, or
payment (including the amount you paid) for a Part
D drug you already received.
If you have problems getting the Part D drugs you What is an exception?
need, or payment for a Part D drug you already re-
An exception is a type of initial determination (also
ceived, you must request an initial determination
called a “coverage determination”) involving a Part
with the plan.
D drug. You or your doctor may ask us to make an
Initial Determinations exception to our Part D coverage rules in a number
The initial determination we make is the starting of situations.
point for dealing with requests you may have about • You may ask us to cover your Part D drug even
covering a Part D drug you need, or paying for a if it is not on our formulary.
Part D drug you already received. Initial determina-
• You may ask us to waive coverage restrictions
tions about Part D drugs are called “coverage de- or limits on your Part D drug. For example, for
terminations.” With this decision, we explain certain Part D drugs, we limit the amount of the
whether we will provide the Part D drug you are drug that we will cover. If your Part D drug has
requesting, or pay for the Part D drug you already a quantity limit, you can ask us to waive the
received. limit and cover more. See the “Utilization
The following are examples of requests for initial Management” section to learn more about our
determinations. (See “What is an exception?” be- additional coverage restrictions or limits on cer-
low for more information about the exceptions tain drugs.
process.) Your doctor must submit a statement support-
• You ask us to pay for a prescription drug you ing your exception request. In order to help us
have received. make a decision more quickly, the supporting
medical information from your doctor should be
• You ask for a Part D drug that is not on our
sent to us with the exception request.
Plan's list of covered drugs (called a "formu-
lary"). This is a request for a "formulary excep- If we approve your exception request, our approval
tion.” is valid for the remainder of the Plan year, so long
as your doctor continues to prescribe the drug for
• You ask for an exception to our utilization
you and it continues to be safe for treating your
management tools - such as prior authorization,
condition. If we deny your exception request, you
dosage limits, quantity limits, or step therapy
may appeal our decision.
requirements. Requesting an exception to a
utilization management tool is a type of formu- Note: If we approve your exception request for
lary exception. a Part D non-formulary drug, you cannot re-
quest an exception to the copayment or coinsur-
• You ask for a non-preferred Part D drug at the
ance amount we require you to pay for the drug.
preferred cost-sharing level. This is a request
for a “tiering exception.” You may call Member Services at 1-888-239-6469
(TTY/TDD: 1-888-239-6482) to ask for any of
• You ask us to pay you back for a drug you
bought at an out-of-network pharmacy. In cer-
tain circumstances, out-of-network purchases, Who may ask for an initial determination?
including drugs provided to you in a physi- You, your prescribing physician, or someone you
cian’s office, will be covered by our Plan. See name may ask us for an initial determination. The
Supplement A for a description of these cir- person you name would be your “appointed repre-
cumstances. You can call us at the above num- sentative.” You may name a relative, friend, advo-
ber to make a request for payment or coverage cate, doctor, or anyone else to act for you. Other
for drugs provided by an out-of-network phar- persons may already be authorized under state law
macy or in a physician’s office. to act for you. If you want someone to act for you,
then you and that person must sign and date a state-
ment that gives the person legal permission to be If you are requesting a Part D drug that you have
your appointed representative. If you are requesting not yet received, you, your doctor, or your ap-
Part D drugs, this statement must be sent to us at: pointed representative may ask us to give you a fast
decision by calling or writing us at the numbers or
Blue Shield of California Medicare Rx Plan
address listed below. If you contact us after regular
Attn: Member Services Department
weekday business hours, please leave a message
PO Box 927
asking for a “fast,” “expedited,” or “24-hour” re-
Woodland Hills, CA 91365
view and we will review your issue within 24 hours
To learn how to name your appointed representa- from the time you leave the message. Be sure to ask
tive, you may call Member Services at 1-888-239- for a “fast,” “expedited,” or “24-hour” review.
6469 (TTY/TDD: 1-888-239-6482).
If your doctor asks for a fast decision for you, or
You also have the right to have a lawyer act for supports you in asking for one, and the doctor indi-
you. You may contact your own lawyer, or get the cates that waiting for a standard decision could se-
name of a lawyer from your local bar association or riously harm your health or your ability to function,
other referral service. There are also groups that we will automatically give you a fast decision.
will give you free legal services if you qualify.
Asking for a “standard” or “fast” initial deter- (TTY/TDD: 1-888-239-6482)
or write us at:
A decision about whether we will give you, or pay
Blue Shield of California Medicare Rx Plan
for, the Part D drug you are requesting can be a
Attn: Member Services Department
“standard” decision that is made within the stan-
PO Box 927
dard time frame, or it can be a “fast” decision that
Woodland Hills, CA 91365
is made more quickly. A fast decision is also called
an “expedited decision.” If you ask for a fast decision without support from a
doctor, we will decide if your health requires a fast
Asking for a standard decision
decision. If we decide that your medical condition
To ask for a standard decision for a Part D drug does not meet the requirements for a fast decision,
you, your doctor, or your representative should call we will send you a letter informing you that if you
or write us at the numbers or address listed below. get a doctor’s support for a fast review, we will
Call: 1-800-535-9481 automatically give you a fast decision. The letter
(TTY/TDD: 1-888-239-6482) will also tell you how to file a “fast grievance.”
You have the right to file a fast grievance if you
or write us at: disagree with our decision to deny your request for
Blue Shield of California Medicare Rx Plan a fast review (for more information, see the section
Attn: Member Services Department on fast grievances). If we deny your request for a
PO Box 927 fast initial determination, we will give you a stan-
Woodland Hills, CA 91365 dard decision.
Asking for a fast decision What happens when you request an initial de-
You may ask for a fast decision only if you or your
doctor believe that waiting for a standard decision • For a standard initial determination about a Part
could seriously harm your health or your ability to D drug (including a request to pay you back for
function. (Fast decisions apply only to requests for a Part D drug that you already received), gener-
benefits that you have not yet received. You cannot ally, we must give you our decision no later
get a fast decision if you are asking us to pay you than 72 hours after we receive your request, but
back for a benefit that you already received.) we will make it sooner if your request is for a
Part D drug that you have not received yet and
your health condition requires it. However, if ready paid for and received, we must send
your request involves a request for an exception payment to you no later than 30 calendar days
(including a formulary exception, tiering excep- after we receive the request (or supporting
tion, or an exception from utilization manage- statement if your requests involves an excep-
ment rules – such as prior authorization, dosage tion).
or quantity limits or step therapy requirements),
• For a fast decision about a Part D drug that you
we must give you our decision no later than 72
have not received, we must cover the Part D
hours after we have received your physician's
drug you requested no later than 24 hours after
"supporting statement," explaining why the
we receive your request. If your request in-
drug you are asking for is medically necessary.
volves a request for an exception, we must
If you have not received an answer from us within cover the Part D drug you requested no later
72 hours after we have received your request, (or than 24 hours after we receive your physician's
your physician’s supporting statement if your re- "supporting statement."
quest involves an exception), your request will
What happens if we decide against you?
automatically go to Appeal Level 2.
If we decide against you, we will send you a written
• For a fast initial determination about a Part D
decision explaining why we denied your request. If
drug that you have not received, if we give you an initial determination does not give you all that
a fast review, we will give you our decision you requested, you have the right to appeal the de-
within 24 hours after you or your doctor ask for cision. (See Appeal Level 1.)
a fast review. We will give you the decision
sooner if your health condition requires it. If Appeal Level 1: Appeal to the Plan
your request involves a request for an excep-
tion, we will give you our decision no later than You may ask us to review our initial determination,
24 hours after we have received your physi- even if only part of our decision is not what you
cian's "supporting statement," which explains requested. An appeal to the plan about a Part D
why the drug you are asking for is medically drug is also called a plan “redetermination.” When
necessary. we receive your request to review the initial deter-
mination, we give the request to people at our or-
If we decide you are eligible for a fast review, and ganization who were not involved in making the
you have not received an answer from us within 24 initial determination. This helps ensure that we will
hours after receiving your request (or your physi- give your request a fresh look.
cian’s supporting statement if your request involves
an exception), your request will automatically go to Who may file your appeal of the initial determi-
Appeal Level 2. nation?
What happens if we decide completely in your If you are appealing an initial decision about a Part
favor? D drug, you or your representative may file a stan-
dard appeal request, or you, your representative,
• For a standard decision about a Part D drug or your doctor may file a fast appeal request.
(including a request to pay you back for a Part Please see “Who may ask for an initial determina-
D drug that you already received), we must tion?” for information about appointing a represen-
cover the Part D drug you requested as quickly tative.
as your health requires, but no later than 72
hours after we receive the request. If your re- How soon must you file your appeal?
quest involves a request for an exception, we You must file the appeal request within 60 calendar
must cover the Part D drug you requested no days from the date included on the notice of our
later than 72 hours after we receive your physi- initial determination. We may give you more time
cian's "supporting statement." If you are asking if you have a good reason for missing the deadline.
us to pay you back for a Part D drug that you al-
How to file your appeal Write us at:
1. Asking for a standard appeal Blue Shield of California Medicare Rx Plan
Attn: Member Services Department
To ask for a standard appeal about a Part D drug, a
PO Box 927
signed written appeal request must be sent to ad-
Woodland Hills, CA 91365
dress listed below.
Getting information to support your appeal
2. Asking for a fast appeal
We must gather all the information we need to
If you are appealing a decision we made about giv-
make a decision about your appeal. If we need your
ing you a Part D drug that you have not received
assistance in gathering this information, we will
yet, you and/or your doctor will need to decide if
contact you or your representative. You have the
you need a fast appeal. The rules about asking for a
right to obtain and include additional information
fast appeal are the same as the rules about asking
as part of your appeal. For example, you may al-
for a fast initial determination. You, your doctor, or
ready have documents related to your request, or
your representative may ask us for a fast appeal by
you may want to get your doctor’s records or opin-
calling or writing us at the phone numbers or ad-
ion to help support your request. You may need to
dress listed below.
give the doctor a written request to get information.
If you contact us after regular weekday business
You may give us your additional information to
hours, please leave a message asking for a “fast,”
support your appeal by calling or writing us at the
“expedited” or “72 hours” review and we will re-
numbers or address listed above. You also have the
view your issue within 72 hours from the time you
right to ask us for a copy of information regarding
leave the message.
your appeal. You may call or write us at the phone
Be sure to ask for a "fast" or "expedited" or “72 numbers or address listed above. We are allowed to
hours” review. Remember, if your doctor provides charge a fee for copying and sending this informa-
a written or oral supporting statement explaining tion to you.
that you need the fast appeal, we will automatically
give you a fast appeal. If you ask for a fast decision How soon must we decide on your appeal?
without support from a doctor, we will decide if • For a standard decision about a Part D drug that
your health requires a fast decision. If we decide includes a request to pay you back for a Part D
that your medical condition does not meet the re- drug you already paid for and received, we will
quirements for a fast decision, we will send you a give you our decision within seven calendar
letter informing you that if you get a doctor’s sup- days after receiving the appeal request. We will
port for a fast review, we will automatically give give you the decision sooner if you have not re-
you a fast decision. The letter will also tell you how ceived the drug yet and your health condition
to file a “fast grievance.” You have the right to file requires it. If we do not give you our decision
a fast grievance if you disagree with our decision to within seven calendar days, your request will
deny your request for a fast review (see the section automatically go to Appeal Level 2.
about fast grievances for more information). If we
• For a fast decision about a Part D drug that you
deny your request for a fast appeal, we will give have not received, we will give you our deci-
you a standard appeal. sion within 72 hours after receiving the appeal
Blue Shield phone numbers and address for ap- request. We will give you the decision sooner if
peals: your health condition requires it. If we do not
give you our decision within 72 hours, your re-
Call us at 1-888-239-6469
quest will automatically go to Appeal Level 2.
What happens if we decide completely in your • For a decision to pay you back for a Part D drug
favor? you already paid for and received, we must
send payment to you within 30 calendar days
• For a standard decision about a Part D drug (in-
from the date we receive notice reversing our
cluding a request to pay you back for a Part D
drug you already received), we must cover the
Part D drug you requested as quickly as your • For a standard decision about a Part D drug you
health requires, but no later than seven calendar have not yet received, we must cover the Part D
days after we receive the request. If you are drug you asked for within 72 hours after we re-
asking us to pay you back for a Part D drug that ceive notice reversing our decision.
you already paid for and received, we must
• For a fast decision about a Part D drug you
send payment to you no later than 30 days after
have not yet received, we must cover the Part D
we receive the request.
drug you asked for within 24 hours after we re-
• For a fast decision about a Part D drug you ceive notice reversing our decision.
have not received, we must cover the Part D
drug you requested no later than 72 hours after Appeal Level 3: Administrative Law
we receive your request. Judge (ALJ)
Appeal Level 2: Independent If the IRE does not rule completely in your favor,
you or your representative may ask for a review by
Review Entity (IRE) an Administrative Law judge (ALJ) if the dollar
At the second level of appeal, your appeal is re- value of the Part D drug you asked for meets the
viewed by an outside, Independent Review Entity minimum requirement provided in the IRE’s deci-
(IRE) that has a contract with the Centers for Medi- sion. During the ALJ review, you may present evi-
care & Medicaid Services (CMS), the government dence, review the record (by either receiving a copy
agency that runs the Medicare program. The IRE of the file or accessing the file in person when fea-
has no connection to us. You have the right to ask sible), and be represented by counsel.
us for a copy of your case file that we sent to this How to file your appeal
entity. We are allowed to charge you a fee for copy-
ing and sending this information to you. The request must be filed with the ALJ within 60
calendar days of the date you were notified of the
How to file your appeal decision made by the IRE (Appeal Level 2). The
If you asked for Part D drugs or payment for Part D ALJ may give you more time if you have a good
drugs and we did not rule completely in your favor reason for missing the deadline. The decision you
at Appeal Level 1, you may file an appeal with the receive from the IRE will tell you how to file this
IRE. If you choose to appeal, you must send the appeal, including who can file it. The ALJ will not
appeal request to the IRE. The decision you receive review your appeal if the dollar value of the re-
from our Plan (Appeal Level 1) will tell you how to quested Part D drug(s) does not meet the minimum
file this appeal, including who can file the appeal requirement provided in the IRE’s decision. If the
and how soon it must be filed. dollar value is less than the minimum requirement,
you may not appeal any further.
How soon must the IRE decide?
How soon will the judge make a decision?
The IRE has the same amount of time to make its
decision as the plan had at Appeal Level 1. The ALJ will hear your case, weigh all of the evi-
dence, and make a decision as soon as possible.
If the IRE decides completely in your favor
If the judge decides in your favor
The IRE will tell you in writing about its decision
and the reasons for it. See the section “Favorable decisions by the ALJ,
MAC or a federal court judge” below for infor-
mation about what we must do if our decision de- How to file your appeal
nying what you asked for is reversed by an ALJ.
In order to request judicial review of your case, you
must file a civil action in a United States district
Appeal Level 4: Medicare Appeals
court within 60 calendar days after the date you
Council (MAC) were notified of the decision made by the Medicare
If the ALJ does not rule completely in your favor, Appeals Council (Appeal Level 4). The letter you
you or your appointed representative may ask for a get from the Medicare Appeals Council will tell
review by the Medicare Appeals Council (MAC). you how to request this review, including who can
file the appeal.
How to file your appeal
Your appeal request will not be reviewed by a fed-
The request must be filed with the MAC within 60
eral court if the dollar value of the requested Part D
calendar days of the date you were notified of the
drug(s) does not meet the minimum requirement
decision made by the ALJ (Appeal Level 3). The
specified in the MAC’s decision.
MAC may give you more time if you have a good
reason for missing the deadline. The decision you How soon will the judge make a decision?
receive from the ALJ will tell you how to file this The federal court judge will first decide whether to
appeal, including who can file it. review your case. If it reviews your case, a decision
How soon will the Council make a decision? will be made according to the rules established by
the federal judiciary.
The MAC will first decide whether to review your
case (it does not review every case it receives). If If the judge decides in your favor
the MAC reviews your case, it will make a decision See the section “Favorable decisions by the ALJ,
as soon as possible. If it decides not to review your MAC, or a federal court judge” below for infor-
case, you may request a review by a federal court mation about what we must do if our decision de-
judge (see Appeal Level 5). The MAC will issue a nying what you asked for is reversed by a federal
written notice explaining any decision it makes. court judge.
The notice will tell you how to request a review by
a federal court judge. If the judge decides against you
If the Council decides in your favor You may have further appeal rights in the federal
courts. Please refer to the judge’s decision for fur-
See the section “Favorable decisions by the ALJ, ther information about your appeal rights.
MAC, or a federal court judge” below for infor-
mation about what we must do if our decision de- Favorable decisions by the ALJ, MAC, or a fed-
nying what you asked for is reversed by the MAC. eral court judge
This section explains what we must do if our initial
Appeal Level 5: Federal Court decision denying what you asked for is reversed by
You have the right to continue your appeal by ask- the ALJ, MAC, or a federal court judge.
ing a federal court judge to review your case if the • For a decision to pay you back for a Part D drug
amount involved meets the minimum requirement you already paid for and received, we must
provided in the Medicare Appeals Council's deci- send payment to you within 30 calendar days
sion, you received a decision from the MAC (Ap- from the date we receive notice reversing our
peal Level 4), and: decision.
• The decision is not completely favorable to • For a standard decision about a Part D drug you
you, or have not yet received, we must cover the Part D
• The decision tells you that the MAC decided drug you asked for within 72 hours after we re-
not to review your appeal request. ceive notice reversing our decision.
• For a fast decision about a Part D drug you If you want to end your membership in our Plan,
have not yet received, we must cover the Part D this is what you need to do:
drug you asked for within 24 hours after we re-
• If you are planning on joining another
ceive notice reversing our decision.
Medicare prescription drug plan: Simply
Ending your membership join the new Medicare Prescription drug plan.
You will be disenrolled automatically from our
Ending your membership in our Plan may be vol- Plan when your new coverage begins on Janu-
untary (your own choice) or involuntary (not your ary 1.
• If you are planning on enrolling in a Medi-
• You might leave our Plan because you have care Advantage plan: Request enrollment in
decided that you want to leave. the new plan. In most cases, you will be disen-
• There are also limited situations where we are rolled automatically when your new plan’s cov-
required to end your membership. erage begins on January 1.
Your group Blue Shield of California Medicare Rx EXCEPTION – If you are joining a Medicare Ad-
Plan is part of the medical coverage obtained vantage “Private Fee-for-Service” plan and that
through your former employer group. If you are plan does not offer drug coverage, or a Medicare
considering making changes to your Medicare Part Medical Savings Account (MSA) Plan, enrollment
D coverage, consult your former employer group’s will not automatically disenroll you from our Plan.
administrator first. Changing Medicare Part D Therefore, you will need to do the following:
plans may affect the current retiree medical cover- - To join a new Medicare prescription drug
age. plan, simply join the new Medicare pre-
Annual Coordinated Election Period scription drug plan, or
Any Medicare beneficiary may make coverage - If you do not want Medicare prescription
changes during the Medicare open enrollment pe- drug coverage, request disenrollment from
riod (also known as the “Annual Election Period”), our Plan by contacting us or calling 1-800-
which occurs every year from November 15 MEDICARE (1-800-633-4227) to request
through December 31. Any changes you make dur- disenrollment from our plan. TTY users
ing this time will be effective January 1. should call 1-877-486-2048.
Former Employer Open Enrollment Period • If you would like to end your membership
without joining any other Medicare health
You may also make coverage changes during your or prescription drug plan: Contact Member
former employer’s open enrollment period. Contact Services to find out how to request disenroll-
your former employer/union benefits administrator ment. You may also call 1-800-MEDICARE
if you have questions on when its open enrollment (1-800-633-4227) to request disenrollment
season is and how it may affect your Part D bene- from our Plan. TTY users should call 1-877-
fits. 486-2048. Your enrollment in Original Medi-
Special Enrollment Periods care will be effective January 1.
You may also qualify to make coverage changes at IMPORTANT – If you disenroll from a Medicare
other times (known as “special enrollment peri- prescription drug plan and go without creditable
ods”). For more information about these times and prescription drug coverage (coverage that is at least
the opportunity available to you, please refer to the as good as Medicare drug coverage), you may have
Medicare and You handbook you receive each fall. to pay a penalty if you join later.
You may also call 1-800-MEDICARE (1-800-633- For more information about the options available to
4277), or visit www.medicare.gov to learn more you during these enrollment periods, contact Medi-
about your options.
care at 1-800-MEDICARE (1-800-633-4227.) TTY • If you knowingly falsify or withhold informa-
users should call 1-877-486-2048. Additional in- tion about other parties that provide reim-
formation can also be found in the “Medicare & bursement for your prescription drug coverage.
You” handbook. This handbook is mailed to every- • If you intentionally give us incorrect informa-
one with Medicare each fall. You may view or tion on your enrollment request that would af-
download a copy from www.medicare.gov - under fect your eligibility to enroll in our Plan.
“Search Tools,” select “Find a Medicare Publica-
tion.” • If you behave in a way that is disruptive, to the
extent that you continued enrollment seriously
Until your membership ends, you must keep impairs our ability to arrange or provide medi-
getting your Medicare prescription drug cover- cal care for you or for others who are members
age through our Plan. of our Plan. We cannot make you leave our
If you leave our Plan, it may take some time for Plan for this reason unless we get permission
your membership to end and your new way of get- first from Medicare.
ting Medicare to take effect (we discuss when the • If you let someone else use your plan member-
change takes effect earlier in this section). While ship card to get medical care. If you are disen-
you are waiting for your membership to end, you rolled for this reason, CMS may refer your case
are still a member and must continue to get your to the Inspector General for additional investi-
prescription drugs as usual through our Plan’s net- gation.
You have the right to make a complaint if we
Until your prescription drug coverage with our Plan
end your membership in our Plan
ends, use our Network Pharmacies to fill your pre-
scriptions. While you are waiting for your member- If we end your membership in our Plan, we will tell
ship to end, you are still a member and must con- you our reasons in writing and explain how you
tinue to get your prescription drugs as usual may file a complaint against us if you want.
through our Plan’s network pharmacies. In most Contact information for our Plan Member Ser-
cases, your prescriptions are covered only if they vices
are filled at a Network Pharmacy, including our
mail service pharmacy, are listed on our formulary, For more information or for questions concerning
and you follow other coverage rules. your Blue Shield of California Medicare Rx Plan,
or to obtain additional information about the drugs
We cannot ask you to leave our Plan because of included on our Plan’s formulary, you may contact
your health. Member Services from 7 a.m. to 8 p.m., seven days
We cannot ask you to leave our Plan for any health- a week, as shown below:
related reasons. If you ever feel that you are being CALL 1-888-239-6469. Calls to this
encouraged or asked to leave our Plan because of number are free.
your health, you should call 1-800-MEDICARE (1-
800-633-4227), which is the national Medicare TTY/TDD 1-888-239-6482. This number re-
help line. TTY users should call 1-877-486-2048. quires special telephone equip-
You may call 24 hours a day, 7 days a week. ment. Calls to this number are free.
Involuntarily ending your membership WRITE Blue Shield of California
If any of the following situations occur, we will Medicare Rx Plan
end your membership in our Plan: Attn: Member Services Dept.
P. O. Box 927
• If you do not stay continuously enrolled in
Woodland Hills, CA 91365
Medicare A or B (or both).
Contact information for grievances, coverage www.medicare.gov and choose “Find Helpful
determinations and appeals Phone Numbers and Resources,” or call 1-800-
MEDICARE (1-800-633-4227). TTY users should
Part D coverage determinations about your Part
D prescription drugs
Health Services Advisory Group, Inc. (HSAG) –
CALL 1-800-535-9481. Calls to this num-
California’s QIO (Quality Improvement Or-
ber are free.
TTY 1-888-239-6482. This number re-
“QIO” stands for Quality Improvement Organiza-
quires special telephone equipment.
tion. The QIO is a group of doctors and health pro-
Calls to this number are free.
fessionals in your state that reviews medical care
WRITE Blue Shield of California and handles certain types of complaints from pa-
Medicare Rx Plan tients with Medicare, and is paid by the federal
Attn: Member Services Dept. government to check on and help improve the care
P. O. Box 927 given to Medicare patients. There is a QIO in each
Woodland Hills, CA 91365 state. QIOs have different names, depending on
Part D grievances about your Part D prescrip- which state they are in.
tion drugs The doctors and other health experts in the QIO
CALL 1-888-239-6469. Calls to this num- review certain types of complaints made by Medi-
ber are free. care patients. These include complaints about qual-
ity of care and appeals filed by Medicare patients
TTY 1-888-239-6482. This number re- who think the coverage for their hospital, skilled
quires special telephone equipment. nursing facility, home health agency, or compre-
Calls to this number are free. hensive outpatient rehabilitation stay is ending too
WRITE Blue Shield of California soon.
Medicare Rx Plan You may contact the Health Services Advisory
Attn: Member Services Dept. Group at:
P. O. Box 927
Woodland Hills, CA 91365 Health Services Advisory Group, Inc.
Attn: Beneficiary Protection
Part D appeals 5201 W. Kennedy Boulevard Suite 900
CALL 1-888-239-6469. Calls to this num- Tampa, Florida 33609-1822
ber are free. HSAG Phone: 1-800-841-1602
TDD #: 1-800-881-5980
TTY 1-888-239-6482. This number re- FAX: 1-866-800-8757
quires special telephone equipment.
Calls to this number are free. Website: www.hsag.com/camedicare
WRITE Blue Shield of California HICAP (Health Insurance Counseling and Ad-
Medicare Rx Plan vocacy Program)
Attn: Member Services Dept. HICAP is a state program that gets money from the
P. O. Box 927 federal government to give free local health insur-
Woodland Hills, CA 91365 ance counseling to people with Medicare. HICAP
Other important contacts can explain your Medicare rights and protections,
help you make complaints about care or treatment,
Below is a list of other important contacts. For the and help straighten out problems with Medicare
most up-to-date contact information, check your bills. HICAP has information about Medicare Ad-
Medicare & You Handbook, visit vantage Plans, Medicare Prescription Drug Plans,
Medicare Cost Plans, and about Medigap (Medi- incomes and resources. In California, this program
care supplement insurance) policies. This includes is called Medi-Cal. Some people with Medicare are
information about whether to drop your Medigap also eligible for Medi-Cal. Medi-Cal has programs
policy while enrolled in a Medicare Advantage that can help pay for your Medicare premiums and
Plan and special Medigap rights for people who other costs, if you qualify. To find out more about
have tried a Medicare Advantage Plan for the first Medi-Cal and its programs, contact your local
time. Medi-Cal office, or please call the California De-
partment of Social Services at 1-800-952-5253
You may contact HICAP at 5380 Elvas Avenue,
(TTY/TDD: 1-800-952-9349), or write to the Cali-
Suite 104, Sacramento, CA 95819, 800-434-0222
fornia Department of Social Services at PO Box
(In-State calls only), 916-231-5110 (Out-of-State
944243, Sacramento, CA 94244.
calls). You may also find the website for HICAP at
www.medicare.gov on the web. Under “Search Social Security
Tools,” select “Helpful Phone Numbers and Web- Social Security programs include retirement bene-
sites.” fits, disability benefits, family benefits, survivors’
How to contact the Medicare program benefits, and benefits for the aged and blind. You
may call Social Security at 1-800-772-1213. TTY
Medicare is the federal health insurance program
users should call 1-800-325-0778. You may also
for people 65 years of age or older, some people
visit www.ssa.gov on the web.
under age 65 with certain disabilities, and people
with end-stage renal disease (generally those with Genetically Handicapped Persons Program
permanent kidney failure who need dialysis or a (GHHP)
kidney transplant). Our organization contracts with
GHPP is a state organization that provides limited
the federal government.
income and medically needy senior citizens and
• Call 1-800-MEDICARE (1-800-633-4227) to individuals with disabilities financial help for pre-
ask questions or get free information booklets scription drugs. You may contact GHPP at:
from Medicare 24 hours a day, seven days a
Genetically Handicapped Persons Program
week. TTY users should call 1-877-486-2048.
Customer service representatives are available
PO Box 997413
24 hours a day, including weekends.
Sacramento, CA 95899-7413
• Visit www.medicare.gov for information. This (916) 327-0470
is the official government website for Medi- 1-800-639-0597
care. This website gives you up-to-date infor- FAX: (916) 327-1112
mation about Medicare and nursing homes and You can also find the website for GHPP at
other current Medicare issues. It includes book- www.dhs.ca.gov/PCFH/cms.ghpp.
lets you can print directly from your computer.
It has tools to help you compare Medicare Ad- Railroad Retirement Board
vantage Plans and Medicare Prescription Drug If you get benefits from the Railroad Retirement
Plans in your area. You can also search under Board, you may call your local Railroad Retirement
“Search Tools” for Medicare contacts in your Board office or 1-800-808-0772. TTY users should
state. Select “Helpful Phone Numbers and call 312-751-4701. You may also visit
Websites.” If you don’t have a computer, your www.rrb.gov on the web.
local library or senior center may be able to
help you visit this website using its computer. Other Employer (or “Group”) coverage
Medicaid If you or your spouse gets benefits from another
employer or union, call the employer/union benefits
Medicaid is a state government program that helps administrator or Member Services if you have any
with medical costs for some people with limited questions about your employer/union benefits, plan
premiums, or the open enrollment season. Impor-
tant Note: You (or your spouse’s) other em-
ployer/union benefits may change, or you (or your
spouse) may lose the benefits, if you enroll in
Medicare Part D. Call your employer/union bene-
fits administrator or Member Services to find out
whether the benefits will change or be terminated if
you or your spouse enrolls in Part D.
Supplement B — Inpatient Substance Abuse Treatment
Summary of Benefits
Benefit Member Copayment
Benefits are provided for Inpatient substance abuse care (including Partial Hospitaliza-
tion1) as described in this Supplement. Benefits are limited to a combined maximum of 30
days each Contract Year.
Inpatient Hospital and Professional Services $100 per day
Partial Hospitalization1 You pay nothing
1 Partial Hospitalization/Day Treatment Program is a treatment program that may be free-standing or Hospital-based and provides
Services at least five (5) hours per day and at least four (4) days per week. Patients may be admitted directly to this level of care,
or transferred from acute Inpatient care following acute stabilization.
In addition to the Benefits described in your Evidence of Cov- Inpatient Hospital and professional Services in connection with
erage and Disclosure Form, your Employer has selected Inpa- hospitalization or Partial Hospitalization for substance abuse
tient substance abuse care Services that supplement your Ac- care are covered when authorized by the MHSA as follows:
cess+ HMO coverage. This supplement describes these Bene-
Inpatient Hospital, Partial Hospitalization, or any combination
fits. (Note: This additional Benefit does not include Inpatient
of these Services are covered up to the maximum calendar
substance abuse medical detoxification, which is a basic
days per contract year as shown in the Summary of Benefits,
medical Benefit of your health Plan.) All Services must be
with one (1) Hospital day counting as one (1) calendar day
Medically Necessary. Residential care is not covered.
and two (2) Partial Hospitalization days counting as one (1)
Blue Shield of California has contracted with a Mental Health calendar day. All Services must be Medically Necessary.
Services Administrator (MHSA) to administer and deliver Residential care is not covered.
Mental Health and Outpatient substance abuse care Services
These Inpatient substance abuse care Services do not count
as well as the Inpatient substance abuse care Services de-
toward the Member’s Maximum Contract Year Copayment
scribed in this Supplement. These Services are provided
through a unique network of MHSA Participating Providers.
All Non-Emergency Inpatient substance abuse care Services
must be obtained from an MHSA Participating Provider and
must be prior authorized by the MHSA. For prior authoriza-
tion for Inpatient substance abuse care Services, Members
should call the MHSA at 1-877-263-9952.
For questions about these Inpatient substance abuse care Ser-
vices, or for assistance in selecting an MHSA Participating
Provider, Members should call the MHSA at 1-877-263-9952.
Supplement C — Acupuncture and Chiropractic Services
Summary of Benefits
Benefit Member Copayment
Covered Services as described in this Supplement and
authorized by American Specialty Health Plans of
California, Inc. (ASH Plans)
Acupuncture Services $15 per visit up to a maximum of 30 visits1 per Contract Year
Chiropractic Services $15 per visit up to a maximum of 30 visits1 per Contract Year
Chiropractic Appliances $50 maximum per Contract Year
The 30-visit maximum is a per Member per Contract Year for chiropractic and acupuncture Services separately.
INTRODUCTION fied above. Benefits are also provided for X-rays and labora-
In addition to the Benefits listed in your Evidence of Coverage
and Disclosure Form, your Plan provides coverage for acu- Chiropractic appliances are covered up to the maximum in a
puncture and chiropractic Services as described in this Sup- Contract Year as shown on the Summary of Benefits as au-
plement. thorized by ASH Plans.
Benefits You will be referred to your Personal Physician for evaluation
of conditions not related to a Neuromusculo-skeletal Disorder,
and for evaluation for non-covered services such as diagnostic
Benefits are provided for Medically Necessary acupuncture scanning (CAT Scans or MRIs).
Services up to the maximum visits* per Contract Year as
*Note: The chiropractic Services visit maximum is a separate
shown on the Summary of Benefits for acupuncture care when
maximum from the acupuncture Services maximum.
received from an American Specialty Health Plans of Califor-
nia, Inc. (ASH Plans) Participating Provider. This Benefit These chiropractic and acupuncture Benefits as described
includes an initial examination and subsequent office visits above are separate from your health plan; however, the gen-
and acupuncture Services specifically for the treatment of eral provisions, limitations and exclusions described in your
Neuromusculo-skeletal Disorders, Nausea and Pain, as author- Evidence of Coverage and Disclosure Form do apply. A refer-
ized by ASH Plans up to the Benefit maximum specified ral from a Member’s physician is not required. All Covered
above. Acupuncture Services that are Covered Services in- Services must be prior authorized by ASH Plans, except for
clude but are not limited to the treatment of carpal tunnel syn- (1) the Medically Necessary initial examination and treatment
drome, headaches, menstrual cramps, osteoarthritis, stroke by a Participating Provider; and, (2) Emergency Services.
rehabilitation, and tennis elbow. Covered Services do not in-
Note: ASH Plans will respond to all requests for prior authori-
clude services for treatment of asthma or addiction (including
zation within 5 business days from receipt of the request.
without limitation, smoking cessation). Covered Services also
do not include vitamins, minerals, nutritional supplements Services provided by Non-Participating Providers will not be
(including herbal supplements) or other similar products. covered except for Emergency Services and in certain circum-
stances, in counties in California in which there are no Partici-
*Note: The acupuncture Services maximum visit is a separate
pating Providers. A Non-Participating Provider is an acupunc-
maximum from the chiropractic Services maximum.
turist or chiropractor who has not entered into an agreement
Chiropractic Services with ASH Plans to provide Covered Services to Members.
Benefits are provided for Medically Necessary chiropractic If you have questions, you may call the ASH Plans Member
Services up to the maximum visits* per Contract Year as Services Department at 1-800-678-9133, or write to: Ameri-
shown on the Summary of Benefits for routine chiropractic can Specialty Health Plans of California, Inc., P.O. Box
care when received from an ASH Plans Participating Pro- 509002, San Diego, CA 92150-9002.
vider. This Benefit includes an initial examination and subse-
Note: Members should exhaust the Covered Services (Bene-
quent office visits, adjustments, and conjunctive therapy spe-
fits) listed and obtained through this Supplement before ac-
cifically for the treatment of Neuromusculo-skeletal Disorders
cessing and utilizing the same services through the
as authorized by ASH Plans up to the Benefit maximum speci-
“mylifepath alternative health services discount program”.
(Members may access the following web site for information might seriously jeopardize the life or health of a Member, or
on the mylifepath discount program: when the Member is experiencing severe pain. Blue Shield
http://www.blueshieldca.com.) shall make a decision and notify the Member and Physician
within 72 hours following the receipt of the request. An ex-
pedited decision may involve admissions, continued stay, or
For all acupuncture and chiropractic Services, Blue Shield of other healthcare services. If you would like additional infor-
California has contracted with ASH Plans to act as the Plan’s mation regarding the expedited decision process, or if you
acupuncture and chiropractic Services administrator. ASH believe your particular situation qualifies for an expedited
Plans should be contacted for questions about acupuncture decision, please contact Blue Shield of California’s Member
and chiropractic Services, ASH Plans Participating Providers, Services Department at the number provided in the back of
or acupuncture and chiropractic Benefits. You may contact your Evidence of Coverage and Disclosure Form booklet.
ASHP at the telephone number or address which appear be-
Note: If your employer’s health plan is governed by the Em-
ployee Retirement Income Security Act (“ERISA”), you may
1-800-678-9133 have the right to bring a civil action under Section 502(a) of
ERISA if all required reviews of your claim have been com-
American Specialty Health Plans of California, Inc.
pleted and your claim has not been approved.
P.O. Box 509002
San Diego, CA 92150-9002 Definitions
ASH Plans can answer many questions over the telephone. American Specialty Health Plans of California, Inc. (ASH
Plans) – ASH Plans is a licensed, specialized health care ser-
vice plan that has entered into an agreement with Blue Shield
Members may contact the Blue Shield Member Services De- of California to arrange for the delivery of acupuncture and
partment by telephone, letter or on-line to request a review of chiropractic Services.
an initial determination concerning a claim or service. Mem-
Nausea – an unpleasant sensation in the abdominal region
bers may contact the Plan at the telephone number as noted in
associated with the desire to vomit that may be appropriately
the back of your Evidence of Coverage and Disclosure Form
treated by a Participating acupuncturist in accordance with
booklet. If the telephone inquiry to Member Services does not
professionally recognized standards of practice and includes
resolve the question or issue to the Member’s satisfaction, the
adult post-operative Nausea and vomiting, and Nausea of
Member may request a grievance at that time, which the
Member Services Representative will initiate on the Mem-
ber’s behalf. Neuromusculo-skeletal Disorders – conditions with associ-
ated signs and symptoms related to the nervous, muscular,
The Member may also initiate a grievance by submitting a
and/or skeletal systems. Neuromusculo-skeletal Disorders are
letter or a completed “Grievance Form”. The Member may
conditions typically categorized as structural, degenerative or
request this Form from Member Services. The completed
inflammatory disorders, or biomechanical dysfunction of the
form should be submitted to Member Services at the address
joints of the body and/or related components of the motor unit
as noted in the back of your Evidence of Coverage and Dis-
(muscles, tendons, fascia, nerves, ligaments/capsules, discs,
closure Form booklet. The Member may also submit the
and synovial structures) and related to neurological manifesta-
grievance online by visiting our web site at
tions or conditions.
Pain – a sensation of hurting or strong discomfort in some
Blue Shield will acknowledge receipt of a grievance within 5
part of the body caused by an injury, illness, disease, func-
calendar days. Grievances are resolved within 30 days. The
tional disorder or condition. Pain includes low back Pain,
grievance system allows Members to file grievances for at
post-operative Pain and post-operative dental Pain.
least 180 days following any incident or action that is the sub-
ject of the Member’s dissatisfaction. See the following para- Participating Provider – a Participating chiropractor, Par-
graph for information on the expedited decision process. ticipating acupuncturist or other licensed health care provider
under contract with ASH Plans to provide Covered Services
Note: Blue Shield of California has established a procedure
for our Members to request an expedited decision. A Mem-
ber, Physician, or representative of a Member may request an
expedited decision when the routine decision making process
Supplement D — Additional Infertility Services
Summary of Benefits
Benefit Member Copayment
Covered Infertility Benefits as described in this Supplement 50%
b) Subject to the Copayment, Infertility Services also in-
In addition to the Benefits listed in your Evidence of Coverage clude the following procedures per lifetime:
and Disclosure Form, your Plan provides coverage for addi-
tional Infertility treatment provided to a Subscriber, spouse or One gamete intrafallopian transfer (GIFT), zygote in-
Domestic Partner covered hereunder as described herein. trafallopian transfer (ZIFT), or in vitro fertilization (IVF)
per lifetime. These procedures are covered only when
For the purpose of this Benefit, Infertility means either with performed on a Subscriber, spouse or Domestic Partner
respect to a Subscriber, spouse or Domestic Partner covered covered hereunder.
The Copayment as shown on the Summary of Benefits is for
1. the presence of a demonstrated bodily malfunction recog- all professional and Hospital Services, ambulatory surgery
nized by a licensed Doctor of Medicine as a cause of In- center and ancillary Services used in connection with any pro-
fertility; cedure covered under this Benefit, and injectable drugs ad-
2. because of a demonstrated bodily malfunction, the inabil- ministered or prescribed by the provider during a course of
ity to conceive a pregnancy or to carry a pregnancy to a treatment to induce fertilization. Procedures must be consis-
live birth after a year or more of regular sexual relations tent with established medical practice in the treatment of Infer-
without contraception; or tility and authorized by the Access+ HMO Personal Physician
and Access+ HMO.
3. because of the inability to conceive a pregnancy after six
cycles of artificial insemination. These initial six cycles Services excluded under this Infertility Benefit are:
are not a benefit of this Plan.
1. Services for or incident to sexual dysfunction
Benefits and sexual inadequacies, except as provided for
Benefits for Infertility Services are provided in addition to treatment of organically based conditions, for
Family Planning Services when authorized by the Access+ which covered Services are provided only un-
HMO Personal Physician and the Access+ HMO and pro- der the medical Benefits portion of your Evi-
vided to a Subscriber, spouse or Domestic Partner covered dence of Coverage and Disclosure Form book-
hereunder with the intention of resulting in conception in that
person. Subject to the Copayments and maximums stated
herein, only the following procedures are covered: 2. Services incident to or resulting from proce-
a) Subject to the Copayment, Infertility Services include dures for a surrogate mother. However, if the
only the following procedures per Contract Year: surrogate mother is enrolled in a Blue Shield of
1. Six natural (without ovum [egg] stimulation) artifi- California health plan, covered Services for
cial inseminations; Pregnancy and Maternity Care for the surro-
2. Three stimulated (with ovum [egg] stimulation) arti- gate mother will be covered under that health
ficial inseminations; plan;
3. Cryopreservation of sperm/eggs/embryos when re- 3. Services for collection, purchase or storage of
trieved from a Subscriber, spouse or Domestic Part- sperm/eggs/frozen embryos from donors other
ner covered hereunder. Benefits are limited to one than the Subscriber or enrolled spouse or en-
retrieval and 1 year of storage per person per life-
time. rolled Domestic Partner as defined, if Domestic
Partners are covered by this plan;
4. Intracytoplasmic sperm injection (ICSI);
5. Services for or incident to a condition which Benefits are limited to a Subscriber, spouse or Do-
the person anticipates may cause Infertility in mestic Partner covered hereunder who has diag-
the future; nosed Infertility as defined at the time services are
6. Any services not specifically listed as a Cov-
ered Service, above.
If your family has more than one Blue Shield HMO Personal Physician, list each family member's name with the name of his or
Family Member _____________________________________________________________________
Personal Physician __________________________________________________________________
Family Member _____________________________________________________________________
Personal Physician __________________________________________________________________
Family Member _____________________________________________________________________
Personal Physician __________________________________________________________________
Police Department __________________________________________________________________
Poison Control Center _______________________________________________________________
Fire Department ____________________________________________________________________
General Emergency 911
Access+ HMO Member Services Department
See last page of this booklet)___________________________________________________________
For information contact Blue Shield of California.
Members may call Blue Shield’s Member Services Department toll free: 1-800-642-6155
For Mental Health Services and information, call the MHSA: 1-877-263-9952
The hearing impaired may call Member Services through Blue Shield’s toll-free TTY number: 1-800-241-1823
Please direct correspondence to:
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
H11054 Retirees (7/09)