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

Coverage Period: Beginning On or After 1/1/2024

Platinum Trio HMO 0/25 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/M0033963_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 $2,350 per individual / $4,700 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.

1 of 8
 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
$25/visit Not Covered ----------------------None-----------------------
injury or illness
Trio+ Specialist: $50/visit Self-referral is available for Trio+
If you visit a health Specialist visit Not Covered
Other Specialist: $50/visit Specialist visits.
care provider's office
You may have to pay for services that
or clinic
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: $20/visit Preauthorization is required. Failure to
X-Ray & Imaging: Not
Diagnostic test (x-ray, blood X-Ray & Imaging: $50/visit obtain preauthorization may result in
Covered
work) Other Diagnostic Examination: non-payment of benefits. The services
Other Diagnostic
$50/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: $200/visit non-payment of benefits.
Covered
Retail:
Level A: $5/prescription Retail: Not Covered
Tier 1 Preauthorization is required for select
If you need drugs to Level B: $10/prescription Mail Service: Not Covered
drugs. Failure to obtain
treat your illness or Mail Service: $10/prescription
preauthorization may result in non-
condition Retail:
payment of benefits.
More information about Level A: $15/prescription Retail: Not Covered
Tier 2 Retail: Covers up to a 30-day supply;
prescription drug Level B: $30/prescription Mail Service: Not Covered
90-days may be covered with a
coverage is available at Mail Service: $30/prescription
copayment for each 30-day supply;
blueshieldca.com/ Retail: Mail Service: Covers up to a 90-day
formulary Level A: $25/prescription Retail: Not Covered
Tier 3 supply.
Level B: $45/prescription Mail Service: Not Covered
Mail Service: $50/prescription

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033963_EOC.pdf. 2 of 8
 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)
Preauthorization is required. Failure to
obtain preauthorization may result in
Retail and Network Specialty non-payment of benefits.
Pharmacies: 20% coinsurance Retail and Network Specialty
up to $250/prescription Retail: Not Covered Pharmacies: Covers up to a 30-day
Tier 4
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.
Ambulatory Surgery Center: Ambulatory Surgery Center:
Facility fee (e.g., ambulatory $100/surgery Not Covered
If you have outpatient
surgery center) Outpatient Hospital: Outpatient Hospital: Not ----------------------None-----------------------
surgery
$150/surgery Covered
Physician/surgeon fees No Charge Not Covered
Facility Fee: $250/visit Facility Fee: $250/visit
Emergency room care ----------------------None-----------------------
Physician Fee: No Charge Physician Fee: No Charge
Emergency medical This payment is for emergency or
$150/transport $150/transport
If you need immediate transportation authorized transport.
medical attention Within Plan Service Area:
Not Covered
Urgent care $25/visit ----------------------None-----------------------
Outside Plan Service Area:
$25/visit
Preauthorization is required. Failure to
$250/day up to 3
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: $25/visit Office Visit: Not Covered
Other Outpatient Services: No Other Outpatient Services:
If you need mental Preauthorization is required except for
Charge Not Covered
health, behavioral office visits and office-based opioid
Outpatient services Partial Hospitalization: No Partial Hospitalization: Not
health, or substance treatment. Failure to obtain
Charge Covered
abuse services preauthorization may result in non-
Psychological Testing: No Psychological Testing: Not
payment of benefits.
Charge Covered

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033963_EOC.pdf. 3 of 8
 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)
Physician Inpatient Services: Physician Inpatient Services:
No Charge Not Covered
Preauthorization is required. Failure to
Hospital Services: $250/day Hospital Services: Not
Inpatient services obtain preauthorization may result in
up to 3 days/admission Covered
non-payment of benefits.
Residential Care: $250/day up Residential Care: Not
to 3 days/admission Covered
Office visits No Charge Not Covered
Childbirth/delivery professional
No Charge Not Covered
If you are pregnant services ----------------------None-----------------------
Childbirth/delivery facility $250/day up to 3
Not Covered
services days/admission
Preauthorization is required. Failure to
obtain preauthorization may result in
Home health care $25/visit Not Covered non-payment of benefits. Coverage
limited to 100 visits per member per
Calendar Year.
Office Visit: Not Covered
Office Visit: $25/visit
Rehabilitation services Outpatient Hospital: Not
Outpatient Hospital: $25/visit
Covered
----------------------None-----------------------
Office Visit: Not Covered
Office Visit: $25/visit
Habilitation services Outpatient Hospital: Not
If you need help Outpatient Hospital: $25/visit
Covered
recovering or have
Preauthorization is required. Failure to
other special health Freestanding SNF: Not
Freestanding SNF: $100/day obtain preauthorization may result in
needs Covered
Skilled nursing care Hospital-based SNF: non-payment of benefits. Coverage
Hospital-based SNF: Not
$100/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.

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033963_EOC.pdf. 4 of 8
 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 limited to one exam per
Children's eye exam No Charge Not Covered
member per Calendar Year.
Coverage is limited to one eyeglass
frame and eyeglass lenses or contact
If your child needs Children's glasses No Charge Not Covered lenses instead of eyeglasses, up to the
dental or eye care benefit per Calendar Year. The cost
listed is for Single Vision.
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

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033963_EOC.pdf. 5 of 8
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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.

Language Access Services:

–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per
Blue Shield of California is an independent member of the Blue Shield Association.
* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033963_EOC.pdf. 6 of 8
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033963_EOC.pdf. 7 of 8
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 $50 ◼ Specialist copayment $50 ◼ Specialist copayment $50
◼ Hospital (facility) copayment $250 ◼ Hospital (facility) copayment $250 ◼ Hospital (facility) copayment $250
◼ Other copayment $20 ◼ Other copayment $20 ◼ Other copayment $50

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 $12,700 Total Example Cost $5,600 Total Example Cost $2,800

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 $900 Copayments $700 Copayments $500
Coinsurance $0 Coinsurance $400 Coinsurance $40
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $960 The total Joe would pay is $1,120 The total Mia would pay is $540

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. 8 of 8
 NOTICES AVAILABLE ONLINE
Nondiscrimination and Language Assistance Services
Blue Shield complies with applicable state and federal civil rights laws. We also offer language assistance services at no additional cost.
View our nondiscrimination notice and language assistance notice: blueshieldca.com/notices.
You can also call for language assistance services: (866) 346-7198 (TTY: 711).

If you are unable to access the website above and would like to receive a copy of the nondiscrimination notice and language assistance notice, please call
Customer Care at (888) 256-3650 (TTY: 711).

Servicios de asistencia en idiomas y avisos de no discriminación

Blue Shield cumple con las leyes de derechos civiles federales y estatales aplicables. También, ofrecemos servicios de asistencia en idiomas sin costo
adicional.

Vea nuestro aviso de no discriminación y nuestro aviso de asistencia en idiomas en blueshieldca.com/notices. Para obtener servicios de asistencia en idiomas,
también puede llamar al (866) 346-7198 (TTY: 711).

Si no puede acceder al sitio web que aparece arriba y desea recibir una copia del aviso de no discriminación y del aviso de asistencia en idiomas, llame a
Atención al Cliente al (888) 256-3650 (TTY: 711).

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䝠鼨〳荝ꨵ㼥宠铃鎊⼿⸔剪⹢(866) 346-7198 (TTY: 711)կ
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Blue Shield of California is an independent member of the Blue Shield Association A52287GEN-NG_0122