go with - Blue Shield of California · is a list of the Providence Southern California acute care...

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Providence OptionPLUS HMO plan

Access+ HMO planEffective January 1, 2014

ii Blue Shield of California

Go with the plan that’s right for you

When you go with Blue Shield, you’re on your way to quality health coverage, large provider networks, and a wide range of proven programs and services that help you get the most value from your coverage.

In this booklet, you’ll find the information you need to choose the right health plan for you and your family, including: Plan benefits and features Additional programs and services available to Blue Shield members

How to find a doctor

Get health plan information anytime, anywhere!

•Fromasmartphonememberscancheckplancoverage,downloadtheir Blue Shield member ID card, get directions to the nearest urgent care center, and more. Just enter blueshieldca.com into the mobile browser.

•OurMemberCentergivesBlueShieldmembersinstantaccesstotheir entire family’s Blue Shield health coverage information from one account. Just go to blueshieldca.com/providence and select Log in.

•TolearnmoreaboutBlueShieldthroughinspiringstoriessharedbyour members, visit blueshieldca.com/memberstories.

1

Plan choices

During the 2014 open enrollment period, Providence is offering two HMO plans: Providence OptionPLUS HMO plan and the Blue Shield Access+ HMO® plan.

Both HMO plans offer the same comprehensive Blue Shield benefits and value-added programs and services. With both plans you’ll need to select your Personal Physician (primary care physician), who is responsible for the overall coordination of your care. You also have the option to self-refer to a specialist within your Personal Physician’s medical group or Independent Practice Association (IPA) for a higher copayment using the Access+ Specialist* referral feature.

Thedifferencebetweentheplansistheprovidernetwork. If you enroll in the Providence OptionPLUS HMO plan, you will have access to a smaller, specially selected network of Providence-affiliated medical groups and affiliated Personal Physicians and specialists than are available in the Access+ HMO plan. Below is a list of the Providence Southern California acute care hospitals that are also included in the Providence OptionPLUS HMO network:

• ProvidenceLittleCompanyofMaryMedicalCenterTorrance

• ProvidenceLittleCompanyofMaryMedicalCenterSan Pedro

• ProvidenceHolyCrossMedicalCenter

• ProvidenceTarzanaMedicalCenter

• ProvidenceSaintJosephMedicalCenter

Enrolling in the Blue Shield Access+ HMO or Providence OptionPLUS HMO plan

When you enroll in either of the HMO plans for the first time, you will need to select your Personal Physician (primary care physician), who will be responsible for the overall coordination of your care, for yourself and your enrolled dependents. You have the option to choose a different Personal Physician and medical group for each enrolledfamilymember.Tofindoutifyourdoctorisinthe Access+ HMO network, you can search online by following the steps on page 4.

If you do not select a Personal Physician at the time of enrollment, Blue Shield will automatically assign a Personal Physician to you and your enrolled family members. You can change your Personal Physician by calling Blue Shield Member Services at (888) 235-1765.

Blue Shield is driven to offering you the right choices for your healthcare coverage

* If your personal physician participates in our access+ specialist program, you may go directly to a specialist in your personal physician’s medical group or ipa without a referral, for a slightly higher copayment. Medical groups and ipas that participate in the access+ specialist program are designated with an a+ in our online and printed directories and on your blue shield member id card.

Open enrollment often brings up lots of questions about health plans and benefits.Ifyouhavequestions,we’vegotanswers.TeamShieldisyourdedicated team of experts ready to help you get the right answers, right away. If you don’t understand particular aspects of your medical coverage, or how to access all the benefits of your health plan, you can go online and post a question. We’ll try to find the answers when you need them.

ConnectwithTeamShieldonFacebookoronTwitter @teamshieldbsc.

teamyour team, your answers

2 Blue Shield of California

Behavioral health benefits

ThebehavioralhealthbenefitsfortheBlueShieldAccess+ and Providence OptionPLUS HMO plans include inpatient and outpatient mental health and substance abuse care for issues such as:

• Depression

• Alcohol/drugabuse

• Mentalillness

• Marriageandfamilycounseling

TheservicesareprovidedbyBlueShield’smentalhealthservice administrator (MHSA) network. HMO members only have access to MHSA network providers.

Care away from home

ThroughtheBlueCard®Program,BlueShieldAccess+and Providence OptionPLUS HMO members can access emergency and urgent care services across the country and around the world. You can receive urgent care services from any provider; however, using the BlueCard Program can be more cost-effective and eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com.

TheAwayFromHomeCare®programgivesstudents,long-term travelers, workers on extended out-of-state assignments, and families living apart the convenience and flexibility of coverage for extended periods across thecountry.TolearnmoreaboutAwayFromHomeCare and whether your family is eligible, call your Blue Shield Member Services team at (888) 235-1765. PleasenotethatAwayFromHomeCareisnotavailablein all areas and states, and benefits from the host plan may differ from the Access+ HMO or Providence OptionPLUS HMO plan.

A website designed just for you!

You have convenient 24-hour access to information about your health benefits at blueshieldca.com/providence. Here you can find a wide range of resources inonecentralizedlocation,including:

•Medical Benefits – Learn about your medical plan features and benefits.

•Find a Provider – Search for doctors and hospitals easily.

•NurseHelp 24/7SM – Get health advice from a registered nurse day or night.

•Programs and Services–Findinformationon programs and services including prenatal and condition management.

Visit blueshieldca.com/providence today!

blueshieldca.com/providence 3

To learn more about these plans, please see the benefit summaries that begin on page 7.

Providence OptionPLUS HMO plan and Access+ HMO plan benefits

Providence OptionPLUS HMO plan and Access+ HMO plan

Annual deductible None

Annual out-of-pocket maximum or copayment maximum $1,500perindividual/$4,500perfamily

Member copayment

Physician office visit $15 per visit

Specialist office visit $15 per physician and specialist office visit $30 per Access+ Specialist visit*

Preventive health benefits No charge

Pregnancy and maternity care benefits† No charge†

Outpatient X-ray, pathology, and laboratory No charge

Hospital care (inpatient non-emergency facility services)

No charge at a Providence Health facility 20% per admission for all other facilities

Rehabilitation benefits (physical, occupational and respiratory therapy)

$15 per visit

Emergency room services (not resulting in admission) $150 per visit

Mental health and substance abuse (outpatient physician visit) $15 per visit

*Tousethisoption,membersmustselectaPersonalPhysicianwhoisaffiliatedwithamedicalgrouporIPAthatisanAccess+providergroup,whichofferstheAccess+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by an MHSA network participating provider.

†Prenatalandpostnatalphysicianofficevisits.Forinpatienthospitalservices,see“HospitalizationServices”onthebenefitsummaryinthebackofthisbooklet.


Search for a network provider online

It’s fast and easy to find a network provider online:

• Gotoblueshieldca.com/providence.

• SelectFind a Provider.

• Choosethetypeofprovideryouwouldlike to search for.

How to find a Personal Physician (Primary Care Physician)

Go to blueshieldca.com/providence and choose Find a Provider.FollowtheinstructionslistedundertheAccess+HMO or Providence OptionPLUS HMO plan.

Find out your provider’s quality of care rankings

You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many individual physicians, HMO medical groups,andhospitals.Toseeaprovider’sperformanceprofile, simply click on the name of the doctor, HMO medical group, or hospital from your search results.

Findanetworkprovider

If you don’t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (888) 235-1765 for personal assistance or to request a provider directory.


Your green light to added benefits, programs, and services

As a member, you can find more information about these programs by going to blueshieldca.com/providence and selecting Log in. If you don’t have a username and password, you can select Register for an online account.

NurseHelp 24/7 – Speak with registered nurses anytime, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chatwitharegisterednurseanytime.TheNurseHelp24/7SM phone number is conveniently located on the back of your member ID card.

LifeReferrals 24/7 – Call anytime to talk with a team of experienced professionals ready to assist you with personal, family, and work issues. Get referrals for three face-to-face visits (in a six-month period) with a licensed therapist at no cost to you (available only in California). TelephoniccounselingsessionswithalicensedtherapistareavailableformembersoutsideofCalifornia.TheLifeReferrals24/7SM phone number is located on the back of your member ID card.

Prenatal Program–Thisprogramgivesexpectantparents24/7accesstoexperiencedmaternitynursesas well as prenatal information including a popular pregnancy or parenting book at no additional cost. Some materials are also available in Spanish.

Condition management programs–Theseprogramsoffer nurse support as well as education and self-management tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease.

Wellness discount programs – Blue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs1 that can help you save money and get healthier.

• 24 Hour Fitness – Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues.

• Weight Watchers – Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits.

• ClubSport and Renaissance ClubSport – Obtain a 60% discount on enrollments when joining with a month-to-month agreement. Enrollment fees are waived whenjoiningwitha12-monthagreement.(Thereisaone-time $25 processing fee when you enroll.)

• Alternative Care Discount Program – Get 25% off usual and customary fees for acupuncture, massage therapy, and chiropractic services, plus get discounts on health and wellness products, with free shipping on most items.

• Discount Provider Network2–Take20%offthepublished retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more.

• MESVision Optics–Takeadvantageofcompetitiveprices on contact lenses,3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50.

• QualSight LASIK – Save on LASIK surgery at more than 45 surgery centers in California. Services include pre-screening, a pre-operative exam, and post-operative visits.

• NVISION Laser Eye Centers – Receive a 15% discount on LASIK surgery from experienced surgeons with offices in Southern California and Sacramento.

• My2020EyesDirect – Get a 20% discount on prescription eyeglasses, sunglasses, and readers.3


1 ThesediscountprogramservicesarenotacoveredbenefitofBlueShieldhealthplans,andnoneofthetermsorconditionsofBlueShieldhealthplansapply.Discount program services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan.

Thenetworksofpractitionersandfacilitiesinthediscountprogramsaremanagedbytheexternalprogramadministratorsidentifiedbelow,includinganyscreening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products.

Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program.

Members who are not satisfied with products or services received from the discount program may use Blue Shield’s grievance process described in the Grievance Process section of the Evidence of Coverage. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

• AlternativeCareDiscountProgram–AmericanSpecialtyHealthSystems,Inc.andAmericanSpecialtyHealthNetworks,Inc.

• DiscountProviderNetworkandMESVisionOptics.com–MESVision

• Weightcontrol–WeightWatchersNorthAmerica

• Fitnessfacilities–24HourFitness,ClubSport,andRenaissanceClubSport

• LASIK–LaserEyeCareofCalifornia,LLC;QualSight,Inc.;andNVISIONLaserEyeCenters

• My2020EyesDirect.com–AdvancedDigitalEyewearInc.

Note: No genetic information, including family medical history, is gathered, shared, or used from these programs.

2 TheDiscountProviderNetworkisavailablethroughoutCalifornia.Coverageinotherstatesmaybelimited.Findparticipatingprovidersbygoingtoblueshieldca.com/fap.

3 Requires a prescription from your doctor or licensed optical professional.

Providence OptionPLUS HMO® Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Blue Shield of California

Effective January 1, 2014 Calendar Year Facility Deductible None Calendar Year Copayment Maximum (For many covered services) $1,500 per Individual /

$4,500 per Family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits • Physician and specialist office visits

(Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services)

$15 per visit

• Outpatient X-ray, pathology and laboratory No Charge Allergy Testing and Treatment Benefits • Office visits (includes visits for allergy serum injections) $15 per visit Access+ SpecialistSM Benefits2 • Office visit, Examination or Other Consultation (Self-referred office visits and consultations

only) $30 per visit

Preventive Health Benefits • Preventive Health Services (As required by applicable federal and California law.) No Charge OUTPATIENT SERVICES Hospital Benefits (Facility Services) • Outpatient surgery performed at an Ambulatory Surgery Center3 No Charge • Outpatient surgery in a hospital No Charge • Outpatient Services for treatment of illness or injury and necessary supplies

(Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") No Charge

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) • Inpatient Physician Services No Charge • Inpatient Non-emergency Providence Health Facility Services (Semi-private room and

board, and medically-necessary Services and supplies, including Subacute Care) • Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-

necessary Services and supplies, including Subacute Care)

No Charge

20% per admission

• Inpatient Medically Necessary skilled nursing Services including Subacute Care at a Providence Health Facility 4

• Inpatient Medically Necessary skilled nursing Services including Subacute Care4, 5

No Charge

20% per admission EMERGENCY HEALTH COVERAGE • Emergency room facility services (The ER copayment does not apply if the member is directly

admitted to the hospital for inpatient services) $150 per visit

• Emergency room Physician Services No Charge AMBULANCE SERVICES • Emergency or authorized transport No Charge

Review benefit summaries

Providence OptionPLUS HMO® Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)





$15 per visit


only) $30 per visit



HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) • Inpatient Physician Services No Charge • Inpatient Non-emergency Providence Health Facility Services (Semi-private room and

board, and medically-necessary Services and supplies, including Subacute Care) • Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-

necessary Services and supplies, including Subacute Care)

No Charge

20% per admission

• Inpatient Medically Necessary skilled nursing Services including Subacute Care at a Providence Health Facility 4

• Inpatient Medically Necessary skilled nursing Services including Subacute Care4, 5

No Charge

20% per admission EMERGENCY HEALTH COVERAGE • Emergency room facility services (The ER copayment does not apply if the member is directly


• Emergency room Physician Services No Charge AMBULANCE SERVICES • Emergency or authorized transport No Charge



Covered Services Member Copayment PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Provided by Express Scripts

(800) 711-0917 PROSTHETICS/ORTHOTICS • Prosthetic equipment and devices (Separate office visit copay may apply) No Charge • Orthotic equipment and devices (Separate office visit copay may apply) No Charge DURABLE MEDICAL EQUIPMENT • Breast pump No Charge • Other Durable Medical Equipment (member share is based upon allowed charges) No Charge MENTAL HEALTH SERVICES (PSYCHIATRIC)6 • Inpatient Hospital Services No Charge • Outpatient Mental Health Services $15 per visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)7 Please see footnote 9 • Chemical dependency and substance abuse services Not Covered HOME HEALTH SERVICES • Home health care agency Services (up to 100 visits per Calendar Year) $15 per visit • Medical supplies (See "Prescription Drug Coverage" for specialty drugs) No Charge OTHER Hospice Program Benefits • Routine home care No Charge • Inpatient Respite Care No Charge • 24-hour Continuous Home Care No Charge • General Inpatient care No Charge Pregnancy and Maternity Care Benefits • Prenatal and postnatal Physician office visits

(For inpatient hospital services, see "Hospitalization Services.") No Charge

Family Planning and Infertility Benefits • Counseling and consulting8 No Charge • Infertility Services (member share is based upon allowed charges)

(Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT).

50%

• Tubal ligation Not Covered • Elective abortion Not Covered • Vasectomy Not Covered Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) • Office location (Copayment applies to all places of services, including professional and facility settings) $15 per visit Speech Therapy Benefits • Office Visit - Services by licensed speech therapists (Copayment applies to all places of

services, including professional and facility settings) $15 per visit

Diabetes Care Benefits • Devices, equipment, and non-testing supplies (member share is based upon allowed charges) No Charge • Diabetes self-management training (by a registered dietician or registered nurse that are certified

diabetes educators) $15 per visit

Hearing Aid Benefits • Hearing examination • Hearing aid and ancillary equipment (Plan payment up to maximum of $5,000 per member every

24 months)

$15 per visit No Charge

Urgent Care Benefits (BlueCard® Program) • Urgent Services outside your Personal Physician Service Area $15 per visit Optional Benefits1 Optional dental, vision, hearing aid, infertility, substance abuse, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

Plan designs may be modified to ensure compliance with state and federal requirements. A15818 (1/14) ML091313 BH092013 BH092413 ML092613 BH1001013

1 Copayments/Coinsurance marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments/Coinsurance and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment 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.

2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider.

3 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits.

4 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met.

5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities.

6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract.

7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield HMO providers.

8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women.

9 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as "Additional Substance Abuse Treatment Benefits."



Providence OptionPLUS HMO plan

Substance Abuse Treatment Benefits Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix)

How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment.1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of California does not provide benefits for services provided by non-participating providers.

Coverage Details Residential care is not covered.

Covered Services Member Copayment2

MHSA Participating Provider

Inpatient Hospitalization No Charge

Professional (Physician) Services - Inpatient and Outpatient Physician Visit

Physician Visit Copay Applies

Partial Hospitalization/Day Treatment Ambulatory Surgery Copay Applies

1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA.

2. Please refer to the Medical Benefit Summary for applicable copayment responsibility.

This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for the exact terms and conditions of coverage.

Access+ HMO® Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)





$15 per visit


only) $30 per visit



HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) • Inpatient Physician Services • Inpatient Non-emergency Providence Health Facility Services (Semi-private room and

board, and medically-necessary Services and supplies, including Subacute Care)

No Charge No Charge

• Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)

20% per admission

• Inpatient Medically Necessary skilled nursing Services including Subacute Care at a Providence Health Facility4

No Charge

• Inpatient Medically Necessary skilled nursing Services including Subacute Care4, 5 20% per admission EMERGENCY HEALTH COVERAGE • Emergency room facility services (The ER copayment does not apply if the member is directly


• Emergency room Physician Services No Charge AMBULANCE SERVICES • Emergency or authorized transport No Charge PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Provided by Express Scripts

(800) 711-0917 PROSTHETICS/ORTHOTICS • Prosthetic equipment and devices (Separate office visit copay may apply) No Charge • Orthotic equipment and devices (Separate office visit copay may apply) No Charge

Access+ HMO® Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)





$15 per visit


only) $30 per visit



HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) • Inpatient Physician Services • Inpatient Non-emergency Providence Health Facility Services (Semi-private room and

board, and medically-necessary Services and supplies, including Subacute Care)

No Charge No Charge

• Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)

20% per admission

• Inpatient Medically Necessary skilled nursing Services including Subacute Care at a Providence Health Facility4

No Charge

• Inpatient Medically Necessary skilled nursing Services including Subacute Care4, 5 20% per admission EMERGENCY HEALTH COVERAGE • Emergency room facility services (The ER copayment does not apply if the member is directly


• Emergency room Physician Services No Charge AMBULANCE SERVICES • Emergency or authorized transport No Charge PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Provided by Express Scripts

(800) 711-0917 PROSTHETICS/ORTHOTICS • Prosthetic equipment and devices (Separate office visit copay may apply) No Charge • Orthotic equipment and devices (Separate office visit copay may apply) No Charge



Covered Services Member Copayment DURABLE MEDICAL EQUIPMENT • Breast pump No Charge • Other Durable Medical Equipment (member share is based upon allowed charges) No Charge MENTAL HEALTH SERVICES (PSYCHIATRIC)6 • Inpatient Hospital Services No Charge • Outpatient Mental Health Services $15 per visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)7 Please see footnote 9 • Chemical dependency and substance abuse services Not Covered HOME HEALTH SERVICES • Home health care agency Services (up to 100 visits per Calendar Year) $15 per visit • Medical supplies (See "Prescription Drug Coverage" for specialty drugs) No Charge OTHER Hospice Program Benefits • Routine home care No Charge • Inpatient Respite Care No Charge • 24-hour Continuous Home Care No Charge • General Inpatient care No Charge Pregnancy and Maternity Care Benefits • Prenatal and postnatal Physician office visits

(For inpatient hospital services, see "Hospitalization Services.") No Charge

Family Planning and Infertility Benefits • Counseling and consulting8 No Charge • Infertility Services (member share is based upon allowed charges)

(Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT).

50%

• Tubal ligation Not Covered • Elective abortion Not Covered • Vasectomy Not Covered Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) • Office location (Copayment applies to all places of services, including professional and facility settings) $15 per visit Speech Therapy Benefits • Office Visit - Services by licensed speech therapists (Copayment applies to all places of

services, including professional and facility settings) $15 per visit

Diabetes Care Benefits • Devices, equipment, and non-testing supplies (member share is based upon allowed charges) No Charge • Diabetes self-management training (by a registered dietician or registered nurse that are certified

diabetes educators) $15 per visit

Hearing Aid Benefits • Hearing examination • Hearing aid and ancillary equipment (Plan payment up to maximum of $5,000 per member every

24 months)

$15 per visit No Charge

Urgent Care Benefits (BlueCard® Program) • Urgent Services outside your Personal Physician Service Area $15 per visit Optional Benefits1 Optional dental, vision, hearing aid, infertility, substance abuse, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

Plan designs may be modified to ensure compliance with state and federal requirements. A15818 (1/14) ML091313 BH092013 BH092413 ML092613










Plan designs may be modified to ensure compliance with state and federal requirements. A15818 (1/14) ML091313 BH092013 BH092413 ML092613












Access+ HMO Plan Substance Abuse Treatment Benefits Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix)

How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment.1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of California does not provide benefits for services provided by non-participating providers.

Coverage Details Residential care is not covered.

Covered Services Member Copayment2

MHSA Participating Provider

Inpatient Hospitalization No Charge

Professional (Physician) Services - Inpatient and Outpatient Physician Visit

Physician Visit Copay Applies

Partial Hospitalization/Day Treatment Ambulatory Surgery Copay Applies

1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA.

2. Please refer to the Medical Benefit Summary for applicable copayment responsibility.

This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for the exact terms and conditions of coverage.

Notice on the availability of language assistance services to accompany vital documents issued in English IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.

You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198.

(Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。

這封信也可以用您所講的語言書寫。如需幫助，請立即撥打登列在您的Blue

Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話866-346-7198。 (Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số 866-346-7198. (Vietnamese)



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Go with Blue Shield

and get on the road

to better health.

Foranyquestions,visitblueshieldca.com/providence or call your dedicated Blue Shield Member Services team at (888) 235-1765, from 7a.m.to7p.m.,MondaythroughFriday.

Member confidentiality

Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number,andSocialSecuritynumber.Toensurethis,BlueShieldrequiresasignedauthorizationformforyou to access health information for your spouse or dependents over the age of 18.

Torequestanauthorizationform,loginto blueshieldca.com and select My Health Plan. Click on Download Formsunder“Tools”ontherightside.Scrolldownto“Releaseofinformation”andclickon Personal and Health Information Release. If you don’t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly at (888) 266-8080.

go with - Blue Shield of California · is a list of the Providence Southern California acute care...

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