Blue Shield HMO Medical at a Glance
Provisions
Blue Shield HMO
General
Must use Blue Shield HMO network providers
  • No annual deductible
  • No annual out-of-pocket maximum
  • No lifetime benefit maximum
  • No pre-existing condition exclusions
Hospital Stay
No charge
Skilled Nursing Facility
No charge; 100-day limit; excludes custodial care
Emergency Room Care
$25 copay/visit for emergencies (waived if admitted); must contact PCP within 24 hours
Outpatient Hospital Care
$10 copay/visit
Maternity Care
No charge
Well-Baby Care
No charge
Office Visits
  • $10 copay/office visit; $30 copay/visit without referral (Access+ Specialist) — must be in the same Medical Group or IPA
  • $10 copay/home visit
Urgent Care Visits
$10 copay/visit
Routine Physical Examinations
$10 copay/visit according to health plan schedule
Immunizations and Injections
  • Immunizations (age 18 and older) — no charge
  • Allergy injections included in office visit
  • Allergy serum purchased separately for treatment — no charge
Eye Examinations
$10 copay/visit for screening; lenses and frames not covered
X-rays and Lab Tests
No charge
Pre-Admission Testing
No charge
Home Health Care
No charge
Hospice Care
No charge
Outpatient Physical Therapy
$10 copay/visit; provided as long as continued treatment is medically necessary pursuant to the treatment plan
Durable Medical Equipment
No charge; pre-authorization required; see plan EOC for limitations and exclusions
Chiropractic Care
Discounts available; contact Member Services for details
Acupuncture
Discounts available; contact Member Services for details
Hearing Aids and related expenses
Covered effective January 1, 2014
100% up to a flat dollar allowance of $2,000 or 80% of the total cost—whichever is greater—for Medically Necessary only. The $2,000 allowance from Blue Shield is available every two years.
Other Benefits
Hearing exams when performed by a physician or by an audiologist at the request of a physician—$10 copay/visit
Prescription Drug Benefits
Retail and mail-order prescription drugs are administered by Blue Shield HMO.
Annual Prescription Drug Deductible (separate from medical plan annual deductible)
None
Annual Prescription Drug Out-of-Pocket Maximum
None
Annual or Lifetime Prescription Drug Maximum Benefit Limit
None
Retail Purchases
Up to 30-day supply — you pay:
  • $5/generic formulary
  • $15/brand formulary
  • $35/non-formulary
Open formulary
Some drugs require pre-authorization
Mail-Order Purchases
For up to 90-day supply — you pay:
  • $10/generic formulary
  • $30/brand formulary
  • $70/non-formulary
Open formulary
Infertility, Sexual Dysfunction, Memory Enhancement and Contraceptive Drugs
Call Blue Shield for details
Mental Health and Substance Abuse (MHSA) Benefits
Blue Shield HMO's medical plan provisions also apply to mental health and substance abuse benefits.
Outpatient Mental Health
  • $10 copay/visit
  • No visit limit
Inpatient Mental Health
No charge; no day limit
Outpatient Substance Abuse
Coverage for Eligible Expenses* through ValueOptions, not HMO; requires referral by ValueOptions
  • $10 copay/visit (individual)
  • $5 copay/visit (group)
  • No visit limit
Inpatient Substance Abuse
Coverage for Eligible Expenses* through ValueOptions, not HMO; requires pre-authorization by ValueOptions
  • 100%
  • No limit on number of stays
Other Information
Eligible Dependents and Member Rights
See a complete description of eligibility, COBRA rights, Qualified Medical Child Support Order procedures and rights, ERISA rights and information, plan funding and plan continuation provisions in this Summary of Benefits Handbook.
Choice of Providers
Members must select a contracting Physician Group where the member wants to receive medical care. That Physician Group will provide or authorize all medical care. Family members may select different contracting Physician Groups. However, each person must select a contracting Physician Group close enough to his or her residence to allow reasonable access to medical care. In addition to selecting a contracting Physician Group, each member must choose a Primary Care Physician from the Physician Group. The Primary Care Physician provides and coordinates medical care. Providers are neither employed nor exclusively contracted by the HMO.
Plan Telephone Number
888-235-1765
Website
* Eligible Expenses" are: (1) expenses for covered health services that are covered by the plan; (2) those that ValueOptions considers "medically necessary" for diagnosis or treatment; and (3) those that do not exceed the "usual and customary" rate as determined by ValueOptions. Any costs not meeting this definition are the responsibility of the member. For additional information or questions, call ValueOptions.