Blue Shield HMO (Access+)
Summary Not Binding
The information contained in this summary is informational. No right shall accrue to you and/or your dependents because of any statement of error, or in omission from, this summary. The HMO's Evidence of Coverage (EOC) is the binding document between the health plan and its members.
The information in this chart is intended as a high-level summary only. The information about the HMOs or the insured products contained in an applicable Evidence of Coverage (EOC) or service provider agreement between the Pacific Gas and Electric Company and the HMO or service provider shall govern in case of conflict between this chart and the EOC or service provider agreement.
If you enroll in Blue Shield HMO, you will receive an Evidence of Coverage, free of charge. It describes in detail Blue Shield HMO benefit provisions, claims procedures, provider network information and other rules. If you need additional information, including a list of participating network providers, you can contact Blue Shield HMO directly.
Summary Chart
This summary chart describes benefits as of January 1, 2013.
The information in this chart is intended as a high-level summary only. The information about the HMOs or the insured products contained in an applicable Evidence of Coverage (EOC) or service provider agreement between the Pacific Gas and Electric Company and the HMO or service provider shall govern in case of conflict between this chart and the EOC or service provider agreement.
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
This Plan's general medical provisions also apply to Mental Health and Substance Abuse (MHSA) benefits.
These benefits are administered both by Blue Shield HMO and by ValueOptions, depending on the type of care you receive.
When care is provided by ValueOptions, pre-authorization is required for inpatient and hospital stays. Care that is not medically necessary will not be covered. For more information on benefits provided by ValueOptions, refer to the Mental Health and Substance Abuse Coverage section.
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.