Blue Shield of California Hmo Dental Fee Schedule Sfsg54

Blue Shield Plan, Benefits, and Rates

Click the (+) to view Access+ HMO summary of benefits.
All the benefits are subject to the definitions, limitations, and exclusions set forth in the Contract Brochure (RI 73-574).

Benefits	You pay
Medical services provided by physicians
Preventive diagnostic and treatment services provided in the office	Office visit copayment: $30 primary care; $40 specialist
Preventive care exam	Nothing
Teladoc (video or phone consultation)	$20 per consult
Lab, X-ray, and other diagnostic tests	Nothing
Services provided by a hospital
Inpatient	$250 per day up to a 3-day maximum copayment
Outpatient	$250 per treatment or surgery
Emergency room (in-area or out-of-area)	$150 copayment per visit
Urgent care	$20 copayment per visit
Maternity care
Prenatal care	Nothing
Screening for gestational diabetes for pregnant women
Delivery
Postnatal care
Prescription drugs
Retail pharmacy (30-day supply)	$10 per Tier 1 prescription
	$50 per Tier 2 prescription
	50% per Tier 3 prescription, $50 minimum/$200 maximum
	30% per Tier 4 prescription, up to $150 max (excluding specialty drugs)
	Network Specialty Pharmacy – 30% per Tier 4 prescription, up to $150 max (includes home self-injectable and specialty drugs)
Retail pharmacy (90-day supply)	$30 per Tier 1 prescription
	$150 per Tier 2 prescription
	50% per Tier 3 prescription, $150 minimum/$600 maximum
	30% per Tier 4 prescription, up to $450 max (excluding specialty drugs)
Mail service (90-day supply)	$20 per Tier 1 prescription
	$100 per Tier 2 prescription
	50% per Tier 3 prescription, $100 minimum/$400 maximum
	30% per Tier 4 prescription, up to $300 max (excluding specialty drugs)
Dental care
Accidental injury benefit	$20 per office visit, or $50 per treatment or surgery
Optional non-FEHB dental plan (Blue Shield Dental HMO or PPO plans)	You pay total premiums plus various copayments
Vision care
Vision care	$20 per office visit
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
Surgical, medical, Rx, mental health, and substance use disorder	Nothing after you have met your $3,000 Self Only/$6,000 Self Plus One/Self and Family enrollment per year out-of-pocket (OOP) max. Some costs do not count toward this protection.
Chiropractic services
Chiropractic services (up to 20 medically necessary visits per year)	$10 per visit

^{* Health Risk Assessment and biometric screenings are for members age 18 and older.}

^†To use this option, members must select a PCP 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 participating mental health service administrator (MHSA) network provider. For ongoing care from a specialist, you'll need to get a referral from your PCP.

^‡The Alternative Care Discount Program is an exclusive offer to Blue Shield Access+ HMO members, made available through an arrangement with American Specialty Health Networks of California, Inc. (ASH Networks) and is not a covered service of any Blue Shield health plan. ASH Networks credentials and manages the program's practitioners. None of the terms and conditions of Blue Shield health plans apply. Blue Shield of California and ASH Networks do not review the program's practitioner services and products for medical necessity or efficacy and makes no representations, claims or guarantees regarding their services or products. Members who use the discount program are responsible for the payment of services provided by participating network practitioners, including payment for cancelled or missed appointments. Members who are not satisfied with services received from the program's practitioners may use the Blue Shield grievance process. Blue Shield reserves the right to terminate this program without notice.

Access+ HMO and Wellvolution are registered trademarks and Access+ Specialist and NurseHelp 24/7 are service marks of Blue Shield of California. Blue Shield and the Shield symbol are registered trademarks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans.

The Blue Shield of California Access+ HMO complies with all applicable Federal civil rights laws, to include both Title VII and Section 1557 of the ACA. Pursuant to Section 1557 the Blue Shield of California Access+ HMO does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex (including pregnancy and gender identity).

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Source: https://myoptions.blueshieldca.com/federal/fep/_/access_hmo_plan

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