PPO Savings

• Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for a copayment/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services. Nonparticipating providers can charge more than Blue Shield’s allowable amounts. When members use non-participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar-year medical deductible or out-of-pocket maximum.
• The maximum allowed charge for nonemergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for the plan’s specific non-network coinsurance percentage of this $600 per day, plus all charges in excess of $600. Amounts that exceed the benefit maximum do not count toward the calendar-year out-of-pocket maximum and continue to be the member’s responsibility after the calendar-year maximums are reached.
• Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, members can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital with payment according to their health plan’s hospital services benefits. Note: Plan designs may be modified to ensure compliance with federal requirements and guidelines, as well as subsequently enacted federal and state legislation.
• Services may require prior authorization. Refer to the evidence of coverage for details.
• Prescription drugs are subject to deductible on HSA-compatible plans. Refer to the evidence of coverage for details.
• Calendar-year integrated medical and pharmacy deductible (all providers combined) applies to both medical and pharmacy services. For family coverage, there is a separate individual deductible within the family deductible. This means that the deductible will be met for a family member when he/she meets the individual deductible or two or more family members meet the family deductible, whichever occurs first. For individuals on family coverage plan, an enrollee can receive benefits for covered services once the individual deductible is met.
• Calendar-year out-of-pocket maximums for participating and non-participating providers are exclusive of each other and include the calendar-year deductible, physician office copays, and prescription drug copays. For family coverage, there is an individual out-of-pocket maximum within the family out-of-pocket maximum. This means that the individual out-of pocket maximum will be met for an individual who meets the individual out-of-pocket maximum prior to the family meeting the family out-of-pocket maximum. Individual will receive 100% of benefits for covered services once the respective individual out-of-pocket maximum is met.

HMO plans

• Copayments/coinsurance and charges for services not accruing to the member’s calendar-year out-of-pocket maximum continue to be the member’s responsibility after the calendar-year out-of-pocket maximum is reached. This amount could be substantial. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.
• Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, members can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to their health plan’s hospital services benefits.

Active Choice plans

• Charges in excess of the allowable amount do not count toward the calendar-year out-of-pocket maximum.
• After the calendar-year out-of-pocket maximum is met, Blue Shield Life covers many benefits at 100% of the allowable amount.
• Please refer to the Certificate of Insurance and Master Group Policy for the exact terms and conditions of coverage.

POS plans

• Emergency room limitations vary between plans and provider levels. See the evidence of coverage and plan contract for exact terms and conditions.
• Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar-year medical deductible is met, the member is responsible for a copayment or coinsurance from participating providers. Participating providers accept Blue Shield's allowable amounts as full payment for covered services. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.
• Non-participating providers can charge more than Blue Shield’s allowable amounts. When members use nonparticipating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar-year medical deductible or out-of-pocket maximum. Calendar-year deductible applies to services of non-participating providers only.
• The maximum allowed charge for nonemergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 30% of this $600 per day, plus all charges in excess of $600.
• The maximum allowed charge for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of this $600 per day, plus all charges in excess of $600.
• Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, members can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to their health plan’s hospital services benefits.
• The maximum allowed charge for nonemergency hospital services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 30% of this $350 per day, plus all charges in excess of $350.
• The maximum allowed charge for nonemergency hospital services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 40% of this $350 per day, plus all charges in excess of $350.
• For non-emergency transport, prior authorization is required and the member is responsible for charges above allowed amount.

Dental HMO plans

• Precious metals and porcelain on molar crowns, if used, will be charged to the member and will be limited to a specific amount based on the plan design.
• In order to be covered, orthodontic treatment must be received in one continuous course of treatment, in consecutive months, and must not exceed 24 consecutive months.

Vision plans

• The comprehensive examination does not include fitting and evaluation fees for contact lenses.
• Fit any frame with an eye size less than 61 mm.
• A change in standard lenses or contacts is permitted per 12-month period if required by qualified prescription change.
• When the participating provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance ($75.47-$99.06) and warehouse allowance ($78.96-$103.64). Note that this pricing replaces the frame allowance shown in the Summary of Benefits ($120-$150). If a more expensive frame is selected at a provider location that uses wholesale or warehouse pricing, the member is responsible for the additional cost above the wholesale or warehouse allowance. Participating providers using wholesale pricing are identified in the Directory of Network Vision Providers. Members pay any cost above the allowed amount.
• Low vision is a bilateral impairment to vision that is so significant that it cannot be corrected with ordinary eyeglasses, contact lenses or intraocular lens implants.
• For members who have had PRK, LASIK or custom LASIK vision correction surgery only, this benefit of plan sunglasses allowance is equal to the plan’s frame allowance. An eye exam by a participating provider or a note from the surgeon who performed the laser surgery is required to verify laser surgery.
• The diabetes disease management referral program is available to members who enroll in both Blue Shield medical and vision coverage.
• Covers one contact lens evaluation provided at time of annual comprehensive exam and two follow-up fittings within a 90-day period. Contact lens allowance may not be combined with frame allowance.

Outpatient prescription drug rider options & for Blue Shield of California and Blue Shield Life riders

• The calendar-year pharmacy deductible is per member per calendar year and applies to covered drugs in Tier 2, 3 and 4. Contraceptive drugs and devices and Tier 1 drugs do not apply to the calendar-year pharmacy deductible.
• When the participating pharmacy’s contracted rate is less than the member’s copayment or coinsurance, the member only pays the contracted rate.
• If the member selects a brand-name drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of the brand-name drug and its generic drug equivalent, as well as the applicable Tier 1 drug copayment.
• For members in HMO and POS plans, drugs from non-participating pharmacies are not covered unless medically necessary for a covered emergency.
• Members in PPO plans who obtain prescription drugs, including contraceptive drugs and devices, at a non-participating pharmacy must first pay all charges for the prescription and submit a completed Prescription Drug Claim Form for reimbursement. The member will be reimbursed the price paid for the drug less any applicable deductible, copayment or coinsurance and any applicable out-of-network charge.
• Outpatient prescription drug copayments for covered drugs obtained from non-participating pharmacies will accrue to the calendar-year medical deductible and the participating provider maximum calendar-year out-of-pocket maximum.
• Select contraceptives, including diaphragms, covered under the outpatient prescription drug benefits do not require a copayment and are not subject to the calendar-year deductible. However, if a brand-name contraceptive is selected when a generic equivalent when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the plan for the brand-name contraceptive and its generic drug equivalent. Select brand contraceptives may need prior authorization in order to waive the copayment or coinsurance. The member may receive up to a 12-month supply of contraceptive drugs.
• For HMO/POS Basic Rx rider: Select drugs and all Tier 3 drugs require prior authorization by Blue Shield for medical necessity, or when effective, lower-cost alternatives are available. If prior authorization is approved for a Tier 3 drug, then the Tier 2 copay will apply.
• Network Specialty Pharmacies dispense specialty drugs which require coordination of care, close monitoring or extensive patient training that generally cannot be met by a retail pharmacy. Networks Specialty Pharmacies also dispense specialty drugs requiring special handling or manufacturing processes, restriction to certain physicians or pharmacies, or reporting certain clinical events to the FDA. Specialty drugs are generally high cost.
• Specialty drugs are covered only when dispensed by a Network Specialty Pharmacy unless medically necessary for a covered emergency. A Network Specialty Pharmacy provides specialty drugs by mail or, upon member request, at an associated retail store for pickup. Oral anticancer medications are not subject to the calendar-year pharmacy deductible.
• Blue Shield’s Short Cycle Specialty Drug Program allows initial prescriptions for select specialty drugs to be dispensed for a 15-day trial supply, as further described in the Evidence of Coverage or Certificate of Insurance. In such circumstances, the applicable Tier 4 copayment or coinsurance will be prorated.
• For Premier Rx Riders: Value-based tier drugs covered for the treatment of hypertension, cholesterol, diabetes, and asthma will not be subject to any applicable calendar-year pharmacy deductible. Please refer to the Evidence of Coverage or Certificate of Insurance for more information.

Endnotes for HSA-compatible HDHPs

• Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar-year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar-year medical deductible and applicable member copayment/coinsurance.
• The allowable amount for non-emergency hospital services received from a non-participating hospital is $2,000 per day. Members are responsible for the coinsurance percentage of this $2,000 per day, plus all charges in excess of $2,000. Charges that exceed the allowable amount do not count toward the calendar-year out-of-pocket maximum.
• Prescription drug coverage information relating to creditable coverage plans can be found in the plan’s SBC or EOC.

Endnotes for off-exchange and mirror HMO plans

• Prescription drug coverage information relating to creditable coverage plans can be found in the plan’s SBC or EOC.
• Drugs obtained at a non-participating pharmacy are not covered, unless medically necessary for a covered emergency, including drugs for emergency contraception.