Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: Beginning On or After 1/1/2020

Gold Access+ HMO® 0/30 OffEx Coverage for: Individual + Family | Plan Type: HMO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit bsca.com/policies/M0019921_EOC.pdf
or call 1-888-319-5999. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1-866-444-3272 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
$0. See the Common Medical Events chart below for your costs for services this plan covers.
deductible?
This plan covers some items and services even if you haven’t yet met the deductible
Are there services Yes. Preventive care and services
amount. But a copayment or coinsurance may apply. For example, this plan covers certain
covered before you meet listed in your complete terms of
preventive services without cost-sharing and before you meet your deductible. See a list of
your deductible? coverage.
covered preventive services at healthcare.gov/coverage/preventive-care-benefits.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
What is the out-of-pocket $6,750 per individual / $13,500 per
other family members in this plan, they have to meet their own out-of-pocket limits until the
limit for this plan? family for participating providers.
overall family out-of-pocket limit has been met.
Copayments for certain services,
What is not included in
premiums, and health care this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
doesn’t cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
Yes. See blueshieldca.com/fad or call network. You will pay the most if you use an out-of-network provider, and you might receive
Will you pay less if you
1-888-319-5999 for a list of network a bill from a provider for the difference between the provider’s charge and what your plan
use a network provider?
providers. pays (balance billing). Be aware, your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to This plan will pay some or all of the costs to see a specialist for covered services but only if
Yes.
see a specialist? you have a referral before you see the specialist.

Blue Shield of California is an independent member of the Blue Shield Association.

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 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an
$30/visit Not Covered ----------------------None-----------------------
injury or illness
Access+ Specialist: $55/visit Self-referral is available for Access+
If you visit a health Specialist visit Not Covered
Other Specialist: $55/visit Specialist visits.
care provider's office
or clinic You may have to pay for services that
Preventive care/screening aren’t preventive. Ask your provider if
No Charge Not Covered
/immunization the services needed are preventive.
Then check what your plan will pay for.
Lab & Path: Not Covered
Lab & Path: $30/visit Preauthorization is required. Failure to
X-Ray & Imaging: Not
Diagnostic test (x-ray, blood X-Ray & Imaging: $55/visit obtain preauthorization may result in
Covered
work) Other Diagnostic Examination: non-payment of benefits. The services
Other Diagnostic
$55/visit listed are at a freestanding location.
If you have a test Examination: Not Covered
Outpatient Radiology Center:
Outpatient Radiology Center: Preauthorization is required. Failure to
Not Covered
Imaging (CT/PET scans, MRIs) $50/visit obtain preauthorization may result in
Outpatient Hospital: Not
Outpatient Hospital: $250/visit non-payment of benefits.
Covered
Retail: $15/prescription Retail: Not Covered Preauthorization is required for select
Tier 1
Mail Service: $30/prescription Mail Service: Not Covered drugs. Failure to obtain
Retail: $35/prescription Retail: Not Covered preauthorization may result in non-
Tier 2
Mail Service: $70/prescription Mail Service: Not Covered payment of benefits.
If you need drugs to Retail: $55/prescription Retail: Covers up to a 30-day supply;
treat your illness or Retail: Not Covered Mail Service: Covers up to a 90-day
Tier 3 Mail Service:
condition Mail Service: Not Covered supply.
$110/prescription
More information about Preauthorization is required. Failure to
prescription drug obtain preauthorization may result in
coverage is available at Retail and Network Specialty
non-payment of benefits.
blueshieldca.com/ Pharmacies: 20% coinsurance
Retail and Network Specialty
formulary up to $250/prescription Retail: Not Covered
Tier 4 Pharmacies: Covers up to a 30-day
Mail Service: 20% Mail Service: Not Covered
supply; Specialty drugs must be
coinsurance up to
obtained at a Network Specialty
$500/prescription
Pharmacy. Mail Service: Covers up to a
90-day supply.
Blue Shield of California is an independent member of the Blue Shield Association.
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 What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
Ambulatory Surgery Center: Ambulatory Surgery Center:
Facility fee (e.g., ambulatory $150/surgery Not Covered
If you have outpatient ----------------------None-----------------------
surgery center) Outpatient Hospital: Outpatient Hospital: Not
surgery $300/surgery Covered
Physician/surgeon fees No Charge Not Covered ----------------------None-----------------------
Facility Fee: $325/visit Facility Fee: $325/visit
Emergency room care ----------------------None-----------------------
Physician Fee: No Charge Physician Fee: No Charge
Emergency medical This payment is for emergency or
$175/transport $175/transport
If you need immediate transportation authorized transport.
medical attention Within Plan Service Area:
Not Covered
Urgent care $30/visit ----------------------None-----------------------
Outside Plan Service Area:
$30/visit
Preauthorization is required. Failure to
$600/day up to 5
If you have a hospital Facility fee (e.g., hospital room) Not Covered obtain preauthorization may result in
days/admission
stay non-payment of benefits.
Physician/surgeon fees No Charge Not Covered ----------------------None-----------------------
Office Visit: $30/visit Office Visit: Not Covered
Other Outpatient Services: No Other Outpatient Services:
Preauthorization is required except for
Charge Not Covered
office visits. Failure to obtain
Outpatient services Partial Hospitalization: No Partial Hospitalization: Not
preauthorization may result in non-
Charge Covered
If you need mental payment of benefits.
Psychological Testing: No Psychological Testing: Not
health, behavioral Charge Covered
health, or substance
abuse services Physician Inpatient Services: Physician Inpatient Services:
No Charge Not Covered
Preauthorization is required. Failure to
Hospital Services: $600/day Hospital Services: Not
Inpatient services obtain preauthorization may result in
up to 5 days/admission Covered
non-payment of benefits.
Residential Care: $600/day up Residential Care: Not
to 5 days/admission Covered
Office visits No Charge Not Covered
If you are pregnant Childbirth/delivery professional ----------------------None-----------------------
No Charge Not Covered
services

Blue Shield of California is an independent member of the Blue Shield Association.

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 What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
Childbirth/delivery facility $600/day up to 5
Not Covered ----------------------None-----------------------
services days/admission
Preauthorization is required. Failure to
obtain preauthorization may result in
Home health care $30/visit Not Covered non-payment of benefits. Coverage
limited to 100 visits per member per
calendar year.
Office Visit: Not Covered
Office Visit: $30/visit
Rehabilitation services Outpatient Hospital: Not
Outpatient Hospital: $30/visit
Covered
----------------------None-----------------------
Office Visit: Not Covered
Office Visit: $30/visit
Habilitation services Outpatient Hospital: Not
If you need help Outpatient Hospital: $30/visit
Covered
recovering or have
other special health Preauthorization is required. Failure to
Freestanding SNF: Not
needs Freestanding SNF: $300/day obtain preauthorization may result in
Covered
Skilled nursing care Hospital-based SNF: non-payment of benefits. Coverage
Hospital-based SNF: Not
$300/day limited to 100 days per member per
Covered
benefit period.
Preauthorization is required. Failure to
Durable medical equipment 50% coinsurance Not Covered obtain preauthorization may result in
non-payment of benefits.
Preauthorization is required except for
pre-hospice consultation. Failure to
Hospice services No Charge Not Covered
obtain preauthorization may result in
non-payment of benefits.
Coverage limited to one exam per
Children's eye exam No Charge Not Covered
member per calendar year.
If your child needs Coverage is limited to one eyeglass
dental or eye care frame and eyeglass lenses or contact
Children's glasses No Charge Not Covered lenses instead of eyeglasses, up to the
benefit per calendar year. The cost
listed is for Single Vision.

Blue Shield of California is an independent member of the Blue Shield Association.

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 What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
Coverage for prophylaxis services
Children's dental check-up No Charge Not Covered (cleaning) is limited to once in a six
month period.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
 Cosmetic surgery  Infertility Treatment  Private-duty nursing  Routine foot care
 Dental care (Adult)  Long-term care  Routine eye care (Adult)  Weight loss programs
 Non-emergency care when
 Hearing Aids
traveling outside the U.S.

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
 Acupuncture  Bariatric surgery  Chiropractic Care

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies
is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or cciio.cms.gov. Other coverage
options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the
Marketplace, visit HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice or assistance, contact:
Blue Shield Customer Service at 1-888-319-5999 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
dol.gov/ebsa/healthreform. Additionally, you can contact the California Department of Managed Health Care Help at 1-888-466-2219 or visit [email protected] or
visit http://www.healthhelp.ca.gov.

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Blue Shield of California is an independent member of the Blue Shield Association.

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Language Access Services:

–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Blue Shield of California is an independent member of the Blue Shield Association.

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of participating pre-natal care and a (a year of routine participating care of a well- (participating emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0
 Specialist copayment $55  Specialist copayment $55  Specialist copayment $55
 Hospital (facility) copayment $600  Hospital (facility) copayment $600  Hospital (facility) copayment $600
 Other copayment $30  Other copayment $30  Other copayment $55

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $1,680 Copayments $1,650 Copayments $560
Coinsurance $0 Coinsurance $860 Coinsurance $40
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0
The total Peg would pay is $1,740 The total Joe would pay is $2,570 The total Mia would pay is $600

Blue Shield of California is an independent member of the Blue Shield Association.

The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 7
 Notice Informing Individuals about Nondiscrimination
and Accessibility Requirements

A49808-DMHC-REV (1/18)
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race,
color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of
California does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability.

Blue Shield of California is an independent member of the Blue Shield Association

Blue Shield of California: Phone: (844) 831-4133 (TTY: 711)
• P
 rovides aids and services at no cost to people with disabilities Fax: (844) 696-6070
to communicate effectively with us such as: Email: [email protected]
- Qualified sign language interpreters You can file a grievance in person or by mail, fax or email. If
Written information in other formats (including large print,
-  you need help filing a grievance, our Civil Rights Coordinator is
audio, accessible electronic formats and other formats) available to help you.
• P
 rovides language services at no cost to people whose primary You can also file a civil rights complaint with the U.S. Department
language is not English such as: of Health and Human Services, Office for Civil Rights electronically
- Qualified interpreters through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
- Information written in other languages
If you need these services, contact the Blue Shield of California U.S. Department of Health and Human Services
Civil Rights Coordinator. 200 Independence Avenue SW.
Room 509F, HHH Building
If you believe that Blue Shield of California has failed to provide Washington, DC 20201
these services or discriminated in another way on the basis of (800) 368-1019; TTY: (800) 537-7697
race, color, national origin, ancestry, religion, sex, marital status,
Complaint forms are available at
gender, gender identity, sexual orientation, age, or disability, www.hhs.gov/ocr/office/file/index.html.
you can file a grievance with:
Blue Shield of California
Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007

Blue Shield of California
50 Beale Street, San Francisco, CA 94105 blueshieldca.com