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Disclosure

VIEWS: 11 PAGES: 20

									      Disclosure




                                                   An Independent Member of the Blue Shield Association
                   ®
   Access+HMO Plan Disclosure Form
With 3-Tier Formulary Prescription Drug Coverage
Blue Shield Disclosure Form:
Access+ HMO® Plan with 3-Tier Formulary
Prescription Drug Coverage
This Disclosure Form is only a summary of your health Plan. You have the right to review the Group
Health Service Contract, which you can obtain from your employer, to determine the terms and conditions
governing your coverage. After you enroll, you will automatically receive an Evidence of Coverage (EOC)
booklet. You should refer to the EOC for detailed information on your health Plan.

PLEASE NOTE
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 information before you
enroll. Call your prospective doctor, medical group, independent practice association,
or clinic, or call Blue Shield’s Member Services at 1-800-424-6521 to ensure that you can
obtain the health care services that you need.

PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF
PROVIDERS HEALTH CARE MAY BE OBTAINED.



Notice
It’s Your Right…
Before you enroll, it’s your right to review this Disclosure Form, and the Uniform Health Plan Benefits and
Coverage Matrix (Benefit Summary) which is a part of this Disclosure Form.

This Disclosure Form is a summary only. The Plan’s Group Health Service Contract
should be consulted to determine governing contractual provisions. A specimen copy of
the Plan Contract will be furnished upon request.

The Evidence of Coverage (EOC) booklet contains the terms and conditions of coverage of your Blue
Shield health Plan. It is your right to view the EOC prior to enrollment in the health Plan.

Please read this Disclosure Form and the EOC carefully and completely so that you understand which
services are covered health care Services, and the limitations and exclusions that apply to the Plan. If
you or your dependents have special health care needs, you should read carefully those sections of the
EOC that apply to those needs.

At the time of your enrollment, Blue Shield of California provides you with a Benefit Summary
summarizing key elements of the Blue Shield of California Group Health Plan you are being offered. This
is to assist you in comparing group health plans available to you and is part of this Disclosure Form. To
obtain a copy of the EOC or if you have questions about the benefits of the Plan, please contact Blue
Shield's Member Services at 1-800-424-6521. The hearing impaired may contact Member Services by
calling the TTY number 1-800-241-1823.
TABLE OF CONTENTS
How the Plan Works ............................................................................................................1
   Choice of Physicians and Providers ............................................................................................. 1
   Local Access+ HMO Plans............................................................................................................ 1
   Referral to Specialty Services........................................................................................................ 1
   Access+ Specialist ......................................................................................................................... 2
   Mental Health and Substance Abuse Services............................................................................ 2
Liability of Subscriber or Enrollee for Payment ...................................................................2
Reimbursement Provisions..................................................................................................2
   Payment of Providers..................................................................................................................... 3
Facilities...............................................................................................................................3
Continuity of Care by a Terminated Provider ......................................................................3
Continuity of Care for New Members by Non-Contracting Providers..................................3
Services for Emergency Care..............................................................................................3
Utilization Review ................................................................................................................4
Principal Benefits and Coverages .......................................................................................4
Principal Exclusions and Limitations on Benefits ................................................................4
   General Exclusions ........................................................................................................................ 4
   Medical Necessity Exclusion ......................................................................................................... 7
Outpatient Prescription Drug Benefit ...................................................................................7
Prepayment Fees ................................................................................................................9
Other Charges .....................................................................................................................9
   Deductibles, Benefit Levels and Maximums ................................................................................ 9
Renewal Provisions ...........................................................................................................10
Plan Changes ....................................................................................................................10
Termination of Benefits......................................................................................................10
   Group Termination ....................................................................................................................... 10
   Individual Termination .................................................................................................................. 10
Individual Continuation of Benefits ....................................................................................10
   Small Employer Cal-COBRA Coverage..................................................................................... 10
   Continuation of Benefits: COBRA ............................................................................................... 10
   Individual Conversion Plan .......................................................................................................... 10
Grievance Process ............................................................................................................10
   External Independent Medical Review ....................................................................................... 11
   Department of Managed Health Care Review......................................................................... 11
Confidentiality of Personal and Health Information ...........................................................11
Definitions ..........................................................................................................................12
                                                          NOTE: A decision will be rendered on all
How the Plan Works                                        requests for prior authorization of services as
                                                          follows:
Choice of Physicians and Providers
                                                              •   for Urgent Services, as soon as possible
   The Access+ HMO offers you health plans with a                 to accommodate the member’s condition
   choice of physicians, hospitals, and Non-                      not to exceed 72 hours from receipt of
   Physician Health Care Practitioners. With the                  the request;
   Access+ HMO, you will be able to select your
   own Personal Physician from the Blue Shield                •   for other services, within 5 business days
   HMO Directory of general practitioners, family                 from receipt of the request. The treating
   practitioners, internists, obstetricians,                      provider will be notified of the decision
   gynecologists, and pediatricians. Each of your                 within 24 hours followed by written notice
   eligible family members may select a different                 to the provider and member within 2
   Personal Physician.                                            business days of the decision.

Local Access+ HMO Plans                                Referral to Specialty Services
   In addition to Access+ HMO Plans, Blue Shield          Specialty Services may be obtained through a
   also offers Local Access+ HMO Plans which              referral from your Personal Physician. The
   have a special network of Independent Practice         Personal Physician is responsible for
   Associations (IPAs) and Medical Groups which           coordinating all of your health care needs and
   includes only a limited number of Plan providers       can best direct you for required specialty
   and a limited Service Area which includes only         Services. Your Personal Physician will generally
   certain counties and cities. These Plans’ special      refer you to a Plan Specialist or Plan Non-
   network is a subset of the entire Access+ HMO          Physician Health Care Practitioner in the same
   network and the Service Area for these Plans is        medical group or IPA as your Personal Physician,
   also a subset of the larger Access+ HMO service        but you can be referred outside the medical
   area.                                                  group or IPA if the type of specialist or Non-
                                                          Physician Health Care Practitioner needed is not
   You have to live and/or work in the Local              available within your Personal Physician’s
   Access+ HMO Plan Service Area in order to              medical group or IPA. The Plan Specialist or
   enroll in a Local Access+ HMO Plan;                    Plan Non-Physician Health Care Practitioner will
   Members enrolled in Local Access+ HMO Plans            provide a complete report to your Personal
   may only select Personal Physicians designated         Physician so that your medical record is
   as Local Access+ HMO Plan providers in the             complete.
   Blue Shield Local Access+ HMO Physician and            Members with a condition or disease that is life-
   Hospital Directory.                                    threatening, degenerative, or disabling which
   All covered Services must be provided by or            requires specialized medical care over a
   arranged through your Personal Physician,              prolonged period of time may be eligible to
   except for the following:                              receive a standing referral to a specialist. To
                                                          receive more information regarding standing
1. Services received during an Access+ Specialist         referrals, contact Member Services.
   visit,
                                                          If there is a question about your diagnosis, plan
2. OB/GYN Services provided by an                         of care, or recommended treatment, including
   obstetrician/gynecologist or a family practice         surgery, or if additional information concerning
   physician within the same medical group/IPA as         your condition would be helpful in determining the
   your Personal Physician,                               diagnosis and the most appropriate plan of
3. Emergency Services,                                    treatment, or if the current treatment plan is not
                                                          improving your medical condition, you may ask
4. Urgent Services outside your Personal                  your Personal Physician to refer you to another
   Physician’s Service Area,                              physician for a second medical opinion. The
5. Mental health and substance abuse Services.*           second opinion will be provided on an expedited
                                                          basis, where appropriate.
   *Mental health and substance abuse Services
   must be arranged and provided through the              If you are requesting a second opinion about care
   Mental Health Services Administrator (MHSA).           you received from your Personal Physician, the
   See the Mental Health and Substance Abuse              second opinion will be provided by a physician
   Services paragraphs later in this section.             within the same medical group/IPA as your
                                                          Personal Physician. If you are requesting a
                                                          second opinion about care received from a
                                                          specialist, the second opinion may be provided
                                                                                                            D-1
      by any Plan Specialist of the same or equivalent
      specialty. All second opinion consultations must
                                                             Liability of Subscriber or Enrollee
      be authorized.                                         for Payment
      Your Personal Physician may also decide to offer         For most covered Services, members pay a fixed
      such a referral even if you do not request it.           dollar Copayment. Some Services are covered
      State law requires that health plans disclose to         at no charge to the member. It is important to
      members, upon request, the timelines for                 note that all Services except for those meeting
      responding to a request for a second medical             the Emergency and out-of-area Urgent Services
      opinion. To request a copy of these timelines,           requirements, Access+ Specialist visits, and all
      you may call the Member Services Department.             mental health and substance abuse Services,
Access+ Specialist                                             must have prior authorization by the Personal
                                                               Physician or the Medical Group/IPA. The
      Through Access+ Specialist, you may arrange an           member will be responsible for payment of
      office visit with a Plan Specialist in the same          services that are not or those that are not an
      medical group or IPA as your Personal Physician          Emergency or covered out-of-area Urgent
      without a referral from your Personal Physician.         Service procedures. Members must obtain
      This benefit is subject to the limitations described     Services from the Plan Providers that are
      in the EOC. The fixed dollar Copay amount for            authorized by their Personal Physician or Medical
      Access+ Specialist visits is indicated on the            Group/IPA and, for all mental health and
      Benefit Summary, which is included as part of            substance abuse Services, from MHSA
      this Disclosure Form.                                    Participating Providers.
Mental Health and Substance Abuse                              If your condition requires Services that are
Services                                                       available from the Plan, payment for services
                                                               rendered by non-Plan providers will not be
      Blue Shield of California has contracted with a          considered unless the medical condition requires
      Mental Health Service Administrator (MHSA) to            Emergency or Urgent Services.
      underwrite and deliver covered mental health and
      substance abuse Services through a unique              Reimbursement Provisions
      network of Mental Health Participating Providers.
      (See Mental Health Service Administrator under           Except as identified below, members do not need
      the Definitions section for more information.) All       to submit claim forms. Members pay fixed dollar
      non-Emergency mental health and substance                or percentage Copayments at the time Services
      abuse Services, except for Access+ Specialist            are received. Percentage Copayments are
      visits, must be arranged through the MHSA.               calculated based on the negotiated rate with the
      Members do not need to arrange for mental                Participating Provider. Some Services are
      health and substance abuse Services through              covered at no charge to the member.
      their Personal Physician.                                If Emergency Services were received and
      All non-Emergency mental health and substance            expenses were incurred by the member for
      abuse Services, except for Emergency or Urgent           services other than medical transportation, the
      Services, must be provided by an MHSA                    member must submit a complete claim with the
      Participating Provider. MHSA Providers are               Emergency Service record for payment to the
      indicated in the Blue Shield of California               Plan within one year after the first provision of
      Behavioral Health Provider Directory. Members            Emergency Services for which payment is
      may contact the MHSA directly for information            requested. In the event covered medical
      on, and to select an, MHSA Provider by calling 1-        transportation Services are obtained in such an
      877-263-8827. Your Personal Physician may                Emergency situation, the Blue Shield Access+
      also contact the MHSA to obtain information              HMO shall pay the medical transportation
      regarding MHSA network Participating Providers           provider directly.
      for you.                                                 If out-of-area Urgent Services were received from
      Mental health and substance abuse services               a provider who is not a participating provider or a
      received from a provider who does not participate        BlueCard* provider, you must submit a complete
      in the MHSA Participating Provider network will          claim with the Urgent Service record for payment
      not be covered, and all charges for these                to the Plan, within one year after the first
      services will be the member’s responsibility.            provision of Urgent Services for which payment is
                                                               requested. The services will be reviewed
                                                               retrospectively by the Plan to determine whether
                                                               the services were Urgent Services. If the Plan
                                                               determines that the services are not covered, it
D-2
   will notify the member of that determination. The
   Plan will notify the member of its determination
                                                        Continuity of Care by a Terminated
   within 30 days from receipt of the claim.            Provider
   *BlueCard is a network of Blue Shield                    Members who are being treated for acute
   participating providers available to members             conditions, serious chronic conditions,
   while temporarily traveling outside of the Service       pregnancies (including immediate postpartum
   Area. If members utilize a BlueCard provider,            care), or terminal illness; or who are children from
   they pay a fixed dollar Copay and no claim form          birth to 36 months of age; or who have received
   is required. The fixed dollar Copay amount is            authorization from a now-terminated provider for
   indicated on the Benefit Summary, which is               surgery or another procedure as part of a
   included as part of this Disclosure Form.                documented course of treatment can request
   Complete information on the BlueCard program             completion of care in certain situations with a
   is contained in the EOC.                                 provider who is leaving the Blue Shield provider
   For groups of 25 employees or less, in 2008, the         network. Contact Member Services to receive
   ratio of the value of health Services provided to        information regarding eligibility criteria and the
   the amount Blue Shield collected in dues was             policy and procedure for requesting continuity of
   70.8 percent. This ratio was calculated after            care from a terminated provider.
   provider discounts were applied. The provider
   discounts exceeded 30 percent of billed charges.     Continuity of Care for New
Payment of Providers                                    Members by Non-Contracting
   Blue Shield generally contracts with groups of       Providers
   physicians to provide Services to members. A             Newly covered members who are being treated
   fixed, monthly fee is paid to the groups of              for acute conditions, serious chronic conditions,
   physicians for each member whose Personal                pregnancies (including immediate postpartum
   Physician is in the group. This payment system,          care), or terminal illness; or who are children from
   capitation, includes incentives to the groups of         birth to 36 months of age; or who have received
   physicians to manage all Services provided to            authorization from a provider for surgery or
   members in an appropriate manner consistent              another procedure as part of a documented
   with the Contract.                                       course of treatment can request completion of
   If you want to know more about this payment              care in certain situations with a non-contracting
   system, contact Member Services at 1-800-424-            provider who was providing services to the
   6521 or talk to your Plan Provider.                      member at the time the member’s coverage
                                                            became effective under this Plan. Contact
Facilities                                                  Member Services to receive information
                                                            regarding eligibility criteria and the written policy
   The Plan has established a network of                    and procedure for requesting continuity of care
   physicians, hospitals, and Non-Physician Health          from a non-contracting provider.
   Care Practitioners in your Personal Physician
   Service Area.                                        Services for Emergency Care
   A more limited subset of this Physician network          Emergency care is covered anywhere in the
   has been established for the Local Access+ HMO           world. Here’s what you need to do:
   Plans; as a result, these Plans have a more
   limited Personal Physician Service Area.             1. In an Emergency, seek care at the nearest
                                                           medical facility.
   Contact Member Services for information on
   Non-Physician Health Care Practitioners in your      2. Members who reasonably believe that they have
   Personal Physician Service Area.                        an Emergency medical condition or mental health
                                                           condition that requires an Emergency response
   Directories of Blue Shield’s providers located in       are encouraged to appropriately use the “911”
   your area will be mailed to you after you enroll.       Emergency response system where available.
   You may also find this information on our Web
   site http://www.blueshieldca.com or by calling       3. You or a family member should notify Blue Shield
   1-800-424-6521.                                         (or the MHSA in the case of mental health
                                                           Services) within 24 hours of receiving inpatient
                                                           Emergency care, or by the end of the first
                                                           business day following treatment, or as soon as it
                                                           is medically possible to provide notice. The
                                                           services will be reviewed retrospectively by the
                                                                                                             D-3
      Plan to determine whether the services were for
      a medical condition for which a reasonable
                                                            Principal Exclusions and Limitations
      person would have believed that she or he had         on Benefits
      an Emergency medical condition.
                                                            General Exclusions
4. For Emergency room visits that do not result in
   direct admission, you pay a fixed dollar Copay.             Blue Shield does not provide benefits for services
   This Copayment does not count toward your                   or procedures that are:
   Copayment Maximum. The fixed dollar Copay
   amount is indicated on the Benefit Summary,
                                                            1. experimental or investigational in nature,
   which is included as part of this Disclosure Form.          except for Services for members who
                                                               have been accepted into an approved
5. If Blue Shield determines that you did not have a
   medical condition for which a reasonable person             clinical trial for cancer as provided in the
   would have believed that he or she had an                   EOC;
   Emergency, your care will not be covered.
                                                            2. for or incident to services rendered in the
6. In an Urgent situation, call your Personal                  home or hospitalization or confinement in
   Physician or the MHSA.                                      a health facility primarily for custodial,
      Please note: For Urgent mental health Services,          maintenance, or domiciliary care, except
      contact the MHSA at the number listed in the             as provided in the EOC; or rest;
      EOC.
                                                            3. for substance abuse treatment or
Utilization Review                                             rehabilitation on an inpatient, partial
      State law requires that health plans disclose to         hospitalization, or outpatient basis,
      members and health plan providers the process            except as specifically provided in the
      used to authorize or deny health care Services           EOC;
      under the Plan.
                                                            4. performed in a hospital by hospital
      Blue Shield has documentation of this process
      (“Utilization Review”), as required under Section        officers, residents, interns, and others in
      1363.5 of the California Health and Safety Code.         training;
      To request a copy of the document describing          5. for or incident to hospitalization or
      this Utilization Review process, call the Member         confinement in a pain management
      Services Department.                                     center to treat or cure chronic pain,
Principal Benefits and Coverages                               except as provided under the Hospice
                                                               Program Services section of the EOC
      The Services and supplies of this health Plan,           and except as Medically Necessary;
      including acute and subacute care, are covered
      only if they are Medically Necessary and              6. for cosmetic surgery or any resulting
      appropriate, and are provided, prescribed, or            complications, except that Medically
      authorized by your Personal Physician or the
                                                               Necessary Services to treat
      MHSA, except for Emergency Services, out-of-
      area Urgent Services, Access+ Specialist visits,         complications of cosmetic surgery (e.g.,
      or OB/GYN Services provided by an obstetrician,          infections or hemorrhages) will be a
      gynecologist, or a family practice physician in the      benefit, but only upon review and
      same medical group or IPA as the member’s                approval by a Blue Shield physician
      Personal Physician. Please refer to the Benefit
                                                               consultant. Without limiting the foregoing,
      Summary, which is included as part of this
      Disclosure Form. Also refer to the EOC, which            no benefits will be provided for the
      you will receive after you enroll. These materials       following surgeries or procedures:
      offer more detailed information on the benefits
      and coverages included in your health Plan.                  •   lower eyelid blepharoplasty;
                                                                   •   spider veins;
                                                                   •   services and procedures to
                                                                       smooth the skin (e.g., chemical


D-4
           face peels, laser resurfacing, and       the result of a diagnosed, identifiable
           abrasive procedures);                    medical condition, injury or illness,
                                                    except as specifically provided in the
       •   hair removal by electrolysis or
                                                    EOC;
           other means; and
                                                 13. for routine foot care including callus, corn
       •   reimplantation of breast implants
                                                     paring or excision, and toenail trimming
           originally provided for cosmetic
                                                     (except as provided under the Hospice
           augmentation;
                                                     Program Services section of the EOC);
7. incident to an organ transplant, except as        treatment (other than surgery) of chronic
   provided in the EOC;                              conditions of the foot, including but not
8. for convenience items such as                     limited to weak or fallen arches, flat or
   telephones, TVs, guest trays, and                 pronated foot, pain or cramp of the foot;
   personal hygiene items;                           bunions, muscle trauma due to exertion,
                                                     or any type of massage procedure on the
9. for transgender or gender dysphoria               foot; for special footwear (e.g., non-
   conditions, including but not limited to          custom made or over-the-counter shoe
   intersex surgery (transsexual                     inserts or arch supports), except as
   operations), or any related services, or          specifically listed as covered in the EOC;
   any resulting medical complications,
   except for treatment of medical               14. for eye refractions, surgery to correct
   complications that is Medically                   refractive error (such as but not limited to
   Necessary;                                        radial keratotomy, refractive
                                                     keratoplasty), lenses and frames for eye
10. for any services related to assisted             glasses, and contact lenses, and video-
    reproductive technology, including but           assisted visual aids or video
    not limited to the harvesting or                 magnification equipment for any
    stimulation of the human ovum, in vitro          purpose, except as provided in the EOC;
    fertilization, Gamete Intrafallopian
    Transfer (G.I.F.T.) procedure, artificial    15. for audiometry examinations for hearing
    insemination, including related                  aids, or hearing aids;
    medications, laboratory, and radiology       16. for dental care or services incident to the
    services, services or medications to treat       treatment, prevention, or relief of pain or
    low sperm count, or services incident to         dysfunction of the temporomandibular
    or resulting from procedures for a               joint and/or muscles of mastication,
    surrogate mother who is otherwise not            except as specifically provided in the
    eligible for Covered Services for                EOC;
    Pregnancy and Maternity Care under a
                                                 17. for or incident to services and supplies
    Blue Shield of California health plan;
                                                     for treatment of the teeth and gums
11. for or incident to the treatment of              (except for tumors and dental and
    Infertility or any form of assisted              orthodontic services that are an integral
    reproductive technology, including but           part of Reconstructive Surgery for cleft
    not limited to the reversal of a vasectomy       palate procedures) and associated
    or tubal ligation, or any resulting              periodontal structures, including but not
    complications, except for medically              limited to diagnostic, preventive,
    necessary treatment of medical                   orthodontic, and other services such as
    complications;                                   dental cleaning, tooth whitening, X-rays,
12. for or incident to speech therapy, speech        topical fluoride treatment except when
    correction, or speech pathology or               used with radiation therapy to the oral
    speech abnormalities that are not likely         cavity, fillings and root canal treatment;
                                                     treatment of periodontal disease or
                                                                                              D-5
      periodontal surgery for inflammatory           Prescription Drugs EOC Supplement, or
      conditions; tooth extraction; dental           in the EOC;
      implants, braces, crowns, dental            27. for contraceptives and contraceptive
      orthoses and prostheses, except as              devices, except as specifically included
      specifically mentioned in the EOC;              in the Family Planning and Infertility
18. for or incident to reading, vocational,           Services benefit and under the
    educational, recreational, art, dance, or         Outpatient Prescription Drugs EOC
    music therapy; weight control ;exercise           Supplement; oral contraceptives and
    programs; or nutritional counseling               diaphragms are excluded, except as may
    except as specifically provided in the            be provided under the Outpatient
    EOC;                                              Prescription Drugs EOC Supplement; no
                                                      benefits are provided for contraceptive
19. for learning disabilities or behavioral
                                                      implants;
    problems or social skills training/therapy;
                                                  28. for transportation services other than
201. for or incident to acupuncture, except
                                                      provided in the EOC;
   as provided in the Acupuncture and
   Chiropractic Services EOC Supplement,          29. for unauthorized non-Emergency
   or in the EOC;                                     Services;
21. for spinal manipulation and adjustment,       30. not provided by, prescribed, referred, or
    except as specifically provided in the            authorized as described herein except
    EOC;                                              for Access+ Specialist visits, OB/GYN
                                                      Services provided by an
22. for or incident to any injury or disease
                                                      obstetrician/gynecologist or family
    arising out of, or in the course of, any
                                                      practice physician within the same
    employment for salary, wage, or profit if
                                                      medical group/IPA as the Personal
    such injury or disease is covered by any
                                                      Physician, Emergency Services or
    workers’ compensation law, occupational
                                                      Urgent Services as provided in the EOC
    disease law, or similar legislation.
                                                      when specific authorization has been
    However, if Blue Shield provides
                                                      obtained in writing for such Services as
    payment for such services, it will be
                                                      described herein, for mental health
    entitled to establish a lien upon such
                                                      Services which must be arranged
    other benefits up to the reasonable cash
                                                      through the MHSA, or for Hospice
    value of benefits provided by Blue Shield
                                                      Services as provided under the Hospice
    for the treatment of the injury or disease
                                                      Program Services section of the EOC;
    as reflected by the providers’ usual billed
    charges;                                      31. performed by a close relative or by a
                                                      person who ordinarily resides in the
23. in connection with private duty nursing,
                                                      member’s or dependent’s home;
    except as provided in the EOC;
                                                  32. for orthopedic shoes, home testing
24 for testing for intelligence or learning
                                                      devices, environmental control
   disabilities;
                                                      equipment, exercise equipment, self
25. for rehabilitation, except as provided in         help/educational devices, or for any type
    the EOC;                                          of communicator, voice enhancer, voice
26. for prescribed drugs and medicines for            prosthesis, electronic voice producing
    outpatient care, except as provided               machine, or any other language
    under the Hospice Program Services                assistance devices, except as provided
    section of the EOC when the member is             in the EOC, and comfort items;
    receiving Hospice Services and except         33. for physical exams required for licensure,
    as may be provided in the Outpatient              employment, or insurance unless the
D-6
   examination corresponds to the schedule       40. for prescription or non-prescription food
   of routine physical examinations                  and nutritional supplements, except as
   provided in the EOC, or for                       provided in the EOC;
   immunizations and vaccinations by any         41. for genetic testing except as described in
   mode of administration (oral, injection or        the in the EOC;
   otherwise) solely for the purpose of
   travel;                                       42. for services provided by an individual or
                                                    entity that is not licensed or certified by
34. for penile implant devices and surgery,         the state to provide health care services,
    and any related services except for any         or is not operating within the scope of
    resulting complications and Medically           such license or certification, except as
    Necessary Services as provided in the           specifically stated in the EOC;
    EOC;
                                                 43. not specifically listed as a benefit.
35. for home testing devices and monitoring
    equipment except as specifically                The Grievance Process portion of the Evidence
                                                    of Coverage provides information on filing a
    provided in the EOC;                            grievance, your right to seek assistance from the
36. for or incident to sexual dysfunctions and      Department of Managed Health Care, and your
                                                    rights to independent medical review.
    sexual inadequacies, except as provided
    for treatment of organically based           Medical Necessity Exclusion
    conditions;                                     All Services must be Medically Necessary. The
37. for non-prescription (over-the-counter)         fact that a physician or other provider may
                                                    prescribe, order, recommend, or approve a
    medical equipment or supplies that can          service or supply does not, in itself, make it
    be purchased without a licensed                 Medically Necessary even though it is not
    provider’s prescription order, even if a        specifically listed as an exclusion or limitation.
    licensed provider writes a prescription         Blue Shield of California may limit or exclude
    order for a non-prescription item, except       benefits for services that are not Medically
                                                    Necessary.
    as specifically provided in the EOC;
38. for reconstructive surgery and               Outpatient Prescription Drug Benefit
    procedures: 1) where there is another           The prescription drug benefit is separate from the
    more appropriate covered surgical               HMO Health Plan coverage. The calendar year
    procedure, or 2) when the surgery or            Copayment Maximum and the Coordination of
                                                    Benefits provision do not apply to the Outpatient
    procedure offers only a minimal
                                                    Prescription Drug benefit.
    improvement in the appearance of the
    enrollee, e.g., spider veins, or 3) as          No benefits are provided for outpatient
                                                    prescription drugs from non-participating
    specifically listed in the EOC;                 pharmacies, except for covered Emergencies,
39. for drugs and medicines that cannot be          including drugs for emergency contraception.
    lawfully marketed without approval of the       For Outpatient Prescription Drug Copayments
    U.S. Food and Drug Administration (the          and for certain plans, Brand Name Drug
    FDA); however, drugs and medicines              Deductibles, please refer to the Benefit
                                                    Summary, which is included as part of this
    that have received FDA approval for             Disclosure Form.
    marketing for one or more uses will not
    be denied on the basis that they are         Outpatient Prescription Drug Formulary
    being prescribed for an off-label use if        Drug coverage is based on the use of the Blue
    the conditions set forth in the California      Shield of California Prescription Drug Formulary.
    Health and Safety Code Section 1367.21          Formularies are lists of preferred, covered
                                                    medications recommended to prescribing
    have been met;                                  physicians. NOTE: the inclusion of a drug in the
                                                    Formulary does not guarantee that it will be
                                                    prescribed by your physician.

                                                                                                    D-7
      Medications are selected for inclusion in Blue          Shield Pharmacy and Therapeutics
      Shield’s Outpatient Prescription Drug Formulary         Committee.
      based on safety, efficacy, FDA bioequivalency
      data, and then cost. New drugs and clinical data     2. Mail Service prescription drugs are
      are reviewed regularly to update the Formulary.         limited to a quantity not to exceed a 90-
      Drugs considered for inclusion or exclusion from
      the Formulary are reviewed by the Blue Shield
                                                              day supply.
      Pharmacy and Therapeutics Committee during           Outpatient Prescription Drug Exclusions
      scheduled meetings four times a year.
                                                              No benefits are provided under the Outpatient
      Members may call the Blue Shield Member                 Prescription Drug benefit for the following (please
      Services department at the number listed on their       note, certain services excluded below may be
      Blue Shield Identification Card to inquire if a         covered under other benefits/portions of your
      specific drug is included in the Formulary. The         Evidence of Coverage – you should refer to the
      Member Services department can also provide             applicable section to determine if drugs are
      members with a printed copy of the Formulary.           covered under that benefit):
      Members may also access the Formulary through
      the Blue Shield of California Web site at            1. drugs obtained from a non-participating
      http://www.blueshieldca.com.                            pharmacy, except for covered
      Selected drugs and drug dosages and most                Emergencies, drugs for emergency
      home self-administered injectables require prior        contraception, and drugs obtained
      authorization by Blue Shield for the less cost          outside of California which are related to
      effective drug alternative will be authorized when      an urgently needed service and for which
      Medically Necessary.
                                                              a Participating Pharmacy was not
      Benefits may be provided for non-Formulary              reasonably accessible;
      drugs subject to higher Copayments.
                                                           2. any drug provided or administered while
Prior     Authorization   Process      for                    the member is an inpatient, or in a
Select Formulary and Non-Formulary Drugs                      physician's office;
and     Most    Home    Self-Administered
Injectables                                                3. take home drugs received from a
      Select Formulary Drugs, as well as most Home
                                                              hospital, convalescent home, skilled
      Self-Administered Injectables may require prior         nursing facility, or similar facility;
      authorization for Medical Necessity. Select Non-
                                                           4. except as specifically listed as covered
      Formulary Drugs may require prior authorization
      for Medical Necessity, and to determine if lower        under the Outpatient Prescription Drugs
      cost alternatives are available and just as             benefit of the EOC Supplement, drugs
      effective. Your Physician may request prior             which can be obtained without a
      authorization by submitting supporting                  prescription or for which there is a non-
      information to Blue Shield. Once all required
                                                              prescription drug that is the identical
      supporting information is received, prior
      authorization approval or denial, based upon            chemical equivalent (i.e., same active
      Medical Necessity, is provided within five              ingredient and dosage) to a prescription
      business days or within 72 hours for an expedited       drug;
      review.
                                                           5. drugs for which the member is not legally
Limitation on Quantity of Drugs that may be                   obligated to pay, or for which no charge
Obtained per Prescription or Refill                           is made;
1. Outpatient prescription drugs are limited
                                                           6. drugs that are considered to be
   to a quantity not to exceed a 30-day
                                                              experimental or investigational;
   supply.
                                                           7. medical devices or supplies, except as
      Some prescriptions are limited to a
                                                              specifically listed as covered under the
      maximum allowable quantity based on
                                                              Outpatient Prescription Drugs benefit of
      Medical Necessity and appropriateness
                                                              the EOC Supplement;
      of therapy as determined by the Blue
                                                           8. blood or blood products;
D-8
9. drugs when prescribed for cosmetic             19. immunizations and vaccinations by any
   purposes, including but not limited to             mode of administration (oral, injection or
   drugs used to retard or reverse the                otherwise) solely for the purpose of
   effects of skin aging or to treat hair loss;       travel.
10. dietary or nutritional products;              20. Drugs packaged in convenience kits that
                                                      include non-prescription convenience
11. injectable drugs which are not self-
                                                      items, unless the Drug is not otherwise
    administered , and all injectable drugs for
                                                      available without the non-prescription
    the treatment of infertility. Other
                                                      components. This exclusion shall not
    injectable medications may be covered
                                                      apply to items used for the administration
    as provided in the EOC;
                                                      of diabetes or asthma Drugs.
12. appetite suppressants or drugs for body          The Grievance Process portion of the Evidence
    weight reduction except when Medically           of Coverage provides information on filing a
    Necessary for the treatment of morbid            grievance, your right to seek assistance from the
    obesity. In such cases the drug will be          Department of Managed Health Care, and your
    subject to prior authorization from Blue         rights to independent medical review.
    Shield;
                                                  Prepayment Fees
13. drugs when prescribed for smoking                The monthly dues for you and your dependents
    cessation purposes (over the counter or          are indicated in your employer’s group Contract.
    by prescription), except to the extent that      Check with your employer regarding the share
    smoking cessation prescription drugs are         you may be required to pay. The initial dues are
    specifically listed as covered under the         payable on the effective date of this health Plan,
                                                     and subsequent dues are payable on the same
    “Drug” definition in the Outpatient              date of each succeeding month.
    Prescription Drugs EOC Supplement;
                                                     All dues required for coverage for you and your
14. contraceptive devices (except                    dependents will be handled through your
    diaphragms), injections, and implants;           employer and must be paid to Blue Shield of
                                                     California.
15. compounded medications if: (1) there is
                                                     The dues of this Plan are subject to change
    a medically appropriate Formulary                following at least 30 days' written notice by Blue
    alternative, or (2) there are no FDA-            Shield to your employer.
    approved indications. Compounded
                                                     NOTE: This section on Prepayment Fees does
    medications that do not include at least         not apply to a member who is enrolled under a
    one Drug, as defined, are not covered;           Contract where monthly dues automatically
                                                     increase, without notice, the first day of the
16. replacement of lost or stolen prescription       month following an age change that moves the
    Drugs;                                           member into the next higher age category. (This
                                                     paragraph applies only to Small Group [2-50
17. pharmaceuticals that are reasonable and          Eligible Employees] Employers.)
    necessary for the palliation and
    management of terminal illness and            Other Charges
    related conditions if they are provided to
                                                  Deductibles, Benefit Levels and
    a member enrolled in a Hospice Program
                                                  Maximums
    through a participating Hospice Agency;
                                                     Certain Blue Shield Access+ HMO Health Plans
18. drugs prescribed for treatment of dental         may have a medical deductible requirement in
    conditions. This exclusion shall not             addition to an Outpatient Prescription Drug Brand
    apply to antibiotics prescribed to treat         Name Drug Deductible included in certain plans.
    infection nor to medications prescribed to       Certain benefits of this health Plan require the
                                                     application of Copayments and charges in
    treat pain;                                      excess of benefit maximums and/or may be
                                                     subject to maximum payments. Please refer to
                                                     the Benefit Summary, which is a part of this
                                                                                                     D-9
    Disclosure Form, to find information regarding the         of dues, you will no longer receive benefits
    maximums that are applicable to the Plan.                  unless you receive an extension of benefits.

Renewal Provisions                                         Individual Termination
                                                               In addition to termination of your employer’s
    Blue Shield of California will offer to renew the
                                                               Group Health Service Contract with Blue Shield,
    Group Health Service Contract except in the
                                                               you will no longer be eligible for coverage under
    following instances:
                                                               the Plan if:
1. non-payment of dues (see the “Termination of
                                                           1. You no longer meet the eligibility requirements in
   Benefits” and “Reinstatement, Cancellation and
                                                              your employer’s Group Health Service Contract;
   Rescission Provisions” sections of the EOC);
                                                           2. You engage in fraud or deception in the use of
2. fraud, misrepresentations, or omissions;
                                                              health Plan benefits;
3. failure to comply with Blue Shield's applicable
                                                           3. You no longer reside or work in the Blue Shield
   eligibility, participation, or contribution rules;
                                                              HMO Plan Service Area.
4. termination of plan type by Blue Shield;
                                                               Please refer to the EOC or your employer’s
5. employer moves out of the Service Area;                     Group Health Service Contract for additional
                                                               information.
6. association membership ceases.
    All groups will renew subject to the above.            Individual Continuation of Benefits
Plan Changes                                                   Please examine your options carefully before
                                                               declining this coverage. You should be aware
    The Benefits of this Plan, including but not limited       that companies selling individual health insurance
    to Covered Services, Deductibles, Copayment,               typically require a review of your medical history
    and annual copayment maximum amounts, are                  that could result in a higher premium or you could
    subject to change at any time. Blue Shield will            be denied coverage entirely.
    provide at least 30 days' written notice of any
    such change to your employer.                          Small Employer Cal-COBRA Coverage
                                                               State law provides that members who enroll in an
Termination of Benefits                                        HMO Group Plan and later lose eligibility may be
                                                               entitled to continuation of group coverage.
Group Termination                                              Please refer to the EOC for information regarding
    The Renewal Provisions section explains the                your eligibility for Cal-COBRA.
    reasons an employer’s Group Health Service
                                                           Continuation of Benefits: COBRA
    Contract may be terminated. Blue Shield may
    cancel the group Contract for non-payment of               If your employment with your current employer
    dues.                                                      ends, you and your covered family members may
                                                               qualify for continued group coverage under the
    If the employer fails to pay the required dues
                                                               Consolidated Omnibus Budget Reconciliation Act
    when due, Blue Shield of California will mail your
                                                               (COBRA) of 1985. The section in the EOC
    employer a notice at least 15 days before any
                                                               entitled Continuation of Group Coverage has
    cancellation of coverage. This notice will provide
                                                               information on COBRA.
    information to your employer regarding the
    consequences of your employer’s failure to pay         Individual Conversion Plan
    the dues due within 15 days of the date the
    notice was mailed.                                         You may also be entitled to continue coverage
                                                               with Blue Shield on an individual conversion plan.
    If Blue Shield’s Group Health Service Contract is          Please refer to the EOC for more details on this
    terminated, you will no longer receive benefits –          option.
    including COBRA (groups with 20 or more
    employees) or Cal-COBRA (groups with 2-19              Grievance Process
    employees). Exceptions due to a disability are
    specifically outlined in the Extension of Benefits         Blue Shield of California has established a
    provision in the EOC.                                      grievance procedure for receiving, resolving, and
                                                               tracking members’ grievances with Blue Shield of
    Remember: If you are hospitalized or undergoing            California. For more information on this process,
    treatment for an ongoing condition and your                see the Grievance Process section in the EOC.
    employer’s Group Health Service Contract is
    cancelled for any reason, including non-payment
D-10
External Independent Medical Review                        the Department of Managed Health Care
                                                           Director.
  State law requires Blue Shield to disclose to
  members the availability of an external
  independent review process when your grievance
                                                         Confidentiality of Personal and
  involves a claim or services for which coverage        Health Information
  was denied by Blue Shield or by a contracting
  provider in whole or in part on the grounds that         Blue Shield is committed to protecting the
  the service is not Medically Necessary or is             personal and health information of our members
  experimental/investigational. You may choose to          in each of the settings in which such information
  make a request to the Department of Managed              is received or exchanged.
  Health Care to have the matter submitted to an           When you complete an application for coverage,
  independent agency for external review in                your signature authorizes Blue Shield to collect
  accordance with California law. For further              personal and health information that includes
  information about whether you qualify or for more        both your medical information and individually
  information about how this review process works,         identifiable information about you such as your
  see the External Independent Medical Review              address, telephone number, or other individual
  section in the EOC.                                      information. If you become a Blue Shield
                                                           member, this general consent allows Blue Shield
Department of Managed Health Care                          to communicate with your physicians and other
Review                                                     providers regarding treatment and payment
  The California Department of Managed Health              decisions.
  Care is responsible for regulating health care           Blue Shield also participates in quality
  service plans. If you have a grievance against           measurement activities that may require us to
  your health Plan, you should first telephone your        access your personal and health information. We
  health Plan at the Member Services                       have policies to protect this information from
  number in your EOC and use your health                   inappropriate disclosure and we release this
  Plan’s grievance process before contacting the           information only if aggregated or encoded. We
  Department. Utilizing this grievance procedure           will not disclose, sell, or otherwise use your
  does not prohibit any potential legal rights or          personal and health information unless permitted
  remedies that may be available to you. If you            by law and to the extent necessary to administer
  need help with a grievance involving an                  the health Plan. We will obtain written
  Emergency, a grievance that has not been                 authorization from you to use your personal and
  satisfactorily resolved by your health Plan, or a        health information for any other purpose. For any
  grievance that has remained unresolved for more          of our prospective or current members unable to
  than 30 days, you may call the Department for            give consent, we have a policy in place to protect
  assistance. You may also be eligible for an              your rights and that permits your legally
  Independent Medical Review (IMR). If you are             authorized representative to give consent on your
  eligible for IMR, the IMR process will provide an        behalf. Blue Shield also will not release your
  impartial review of medical decisions made by a          personal and health information to your employer
  health plan related to the medical necessity of a        without your specific authorization, unless such
  proposed service or treatment, coverage                  release is permitted by law.
  decisions for treatments that are experimental or
                                                           Through its contracts with providers, Blue Shield
  investigational in nature, and payment disputes
                                                           has policies in place to allow you to inspect your
  for Emergency or Urgent medical services. The
                                                           medical records maintained by your provider and,
  Department also has a toll-free telephone
                                                           when needed, to include a written statement from
  number (1-888-HMO-2219) and a TDD line                   you. You also have the right to review personal
  (1-877-688-9891) for the hearing and speech              and health information that may be maintained by
  impaired. The Department’s Internet Web site             Blue Shield.
  (http://www.hmohelp.ca.gov) has complaint                If you are a prospective, current, or former
  forms, IMR application forms, and instructions           member and need more detailed information
  online.                                                  about Blue Shield's Corporate Confidentiality
  In the event that Blue Shield should cancel or           policy, it is available on Blue Shield's Web site at
  refuse to renew the enrollment for you or your           http://www.blueshieldca.com or by calling
  dependents and you feel that such action was             Member Services.
  due to reasons of health or utilization of benefits,
  you or your dependents may request a review by


                                                                                                          D-11
   STATEMENT DESCRIBING BLUE                                  Medically Necessary – the benefits of this Plan
                                                              are provided only for Services that are Medically
SHIELD’S POLICIES AND PROCEDURES                              Necessary.
       FOR PRESERVING THE
   CONFIDENTIALITY OF MEDICAL                                 Services that are Medically Necessary include
                                                              only those that have been established as safe
RECORDS IS AVAILABLE AND WILL BE                              and effective and are furnished in accordance
FURNISHED TO YOU UPON REQUEST.                                with generally accepted professional standards to
                                                              treat an illness, injury, or medical condition, and
Definitions                                                   that, as determined by Blue Shield, are:

    Allowed Charges — the amount a Plan Provider         a. consistent with Blue Shield Medical Policy; and,
    agrees to accept as payment from Blue Shield or      b. consistent with the symptoms or diagnosis; and,
    the billed amount for non-Plan Providers (except
    that physicians rendering Emergency Services         c.   not furnished primarily for the convenience of the
    and hospitals rendering any Services who are not          patient, the attending physician, or other provider;
    Plan Providers will be paid based on the             d. furnished at the most appropriate level that can
    Reasonable & Customary Charge, as defined).             be provided safely and effectively to the patient;
    Access+ Provider – a medical group or IPA, and          and,
    all associated physicians and Plan Specialists,           If there are two or more Medically Necessary
    that participate in the Access+ HMO Plan and, for         services that may be provided for the illness,
    mental health and substance abuse Services, an            injury or medical condition, Blue Shield will
    MHSA Participating Provider.                              provide benefits based on the most cost-effective
    Copayment – the amount that a member is                   service.
    required to pay for specific Covered Services.            Hospital inpatient Services that are Medically
    Copayment Maximum – the maximum amount                    Necessary include only those Services that
    you pay in a calendar year for certain Services.          satisfy the above requirements, require the acute
    Check the Benefit Summary for specific                    bed-patient (overnight) setting, and that could not
    information on the Copayment Maximum for your             have been provided in a physician’s office, the
    Plan.                                                     outpatient department of a hospital, or in another
                                                              lesser facility without adversely affecting the
    Emergency Services – services provided for an             patient’s condition or the quality of medical care
    unexpected medical condition, including a                 rendered.
    psychiatric Emergency medical condition,
    manifesting itself by acute symptoms of sufficient        Inpatient services that are not Medically
    severity (including severe pain) such that the            Necessary include hospitalization:
    absence of immediate medical attention could         a. for diagnostic studies that could have been
    reasonably be expected to result in any of the          provided on an outpatient basis;
    following:
                                                         b. for medical observation or evaluation;
1. placing the member’s health in serious jeopardy;
                                                         c.   for personal comfort;
2. serious impairment to bodily functions;
                                                         d. in a pain management center to treat or cure
3. serious dysfunction of any bodily organ or part.         chronic pain; or
    Group Health Service Contract (Contract) –           e. for inpatient rehabilitation that can be provided on
    the Contract issued by the Plan to the                  an outpatient basis.
    contractholder/employer that establishes the
    Services members are entitled to receive from             Blue Shield reserves the right to review all
    the Plan.                                                 services to determine whether they are Medically
                                                              Necessary.
    Independent Practice Association (IPA) – a
    group of physicians with individual offices who           Mental Health Service Administrator (MHSA) –
    form an organization in order to contract,                The MHSA is a specialized health care service
    manage, and share financial responsibilities for          plan contracted to underwrite and deliver the
    providing benefits to members. For all mental             Plan’s mental health and substance abuse
    health and substance abuse Services, this                 Services through a separate network of MHSA
    definition includes the Mental Health Service             Participating Providers.
    Administrator (MHSA).                                     MHSA Participating Providers – providers who
                                                              have an agreement in effect with the MHSA for

D-12
the provision of mental health and substance            Urgent Services – those covered Services
abuse Services.                                         rendered outside of the Plan’s Service Area
                                                        (other than Emergency Services) that are
Personal Physician – a general practitioner,
                                                        Medically Necessary to prevent serious
board-certified or eligible family practitioner,
                                                        deterioration of a member's health resulting from
internist, obstetrician/gynecologist, or pediatrician
                                                        unforeseen illness, injury, or complications of an
who has contracted with the Plan as a Personal
                                                        existing medical condition, for which treatment
Physician to provide primary care to members
                                                        cannot reasonably be delayed until the member
and to refer, authorize, supervise, and coordinate
                                                        returns to the Plan's Service Area.
the provision of all benefits to members in
accordance with the Contract.
Personal Physician Service Area – that
geographic area served by your Personal
Physician’s medical group or IPA.
Plan – the Blue Shield of California Access+
HMO Plan.
Plan Non-Physician Health Care Practitioner –
a health care professional who is not a physician
and has an agreement with one of the contracted
Independent Practice Associations, medical
groups, Plan hospitals, or Blue Shield to provide
covered Services to members when referred by a
Personal Physician. For all mental health and
substance abuse Services, this definition
includes Mental Health Service Administrator
(MHSA) Participating Providers.
Plan Service Area – that geographic area
served by the Plan.
Plan Specialist – a physician other than a
Personal Physician, psychologist, licensed
clinical social worker, or licensed marriage and
family therapist who has an agreement with Blue
Shield to provide covered Services to members
either according to an authorized referral by a
Personal Physician, or according to the Access+
Specialist program, or for OB/GYN physician
Services. For all mental health and substance
abuse Services, this definition includes Mental
Health Service Administrator (MHSA)
Participating Providers.
Reasonable & Customary Charge — In
California: The lower of (1) the provider’s billed
charge, or (2) the amount determined by the Plan
to be the reasonable and customary value for the
services rendered by a non-Plan Provider based
on statistical information that is updated at least
annually and considers many factors including,
but not limited to, the provider’s training and
experience, and the geographic area where the
services are rendered; Outside of California: The
lower of (1) the provider’s billed charge, or, (2)
the amount, if any, established by the laws of the
state to be paid for Emergency Services.
Services – includes Medically Necessary health
care services and Medically Necessary supplies
furnished incident to those services.

                                                                                                      D-13
A12033-21 (7/10)
A12033-21 (7/10)

								
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