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

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

Bronze 60 PPO Coverage for: Individual + Family | Plan Type: PPO
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/MJ002189_EOC.pdf
or call 1-888-256-3650. 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:
$6,300 per individual / $12,600 per Generally, you must pay all of the costs from providers up to the deductible amount before
What is the overall family for participating providers; this plan begins to pay. If you have other family members on the plan each family member
deductible? $12,600 per individual / $25,200 per must meet their own individual deductible until the total amount of deductible expenses paid
family for non-participating providers. by all family members meets the overall family 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 Yes. Prescription drugs -- $500 per
You must pay all of the costs for these services up to the specific deductible amount before
deductibles for specific individual / $1,000 per family. There are
this plan begins to pay for these services.
services? no other specific deductibles.
$9,100 per individual / $18,200 per
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 family for participating providers;
other family members in this plan, they have to meet their own out-of-pocket limits until the
limit for this plan? $20,000 per individual / $40,000 per
overall family out-of-pocket limit has been met.
family for non-participating providers.
Copayments for certain services,
What is not included in
premiums, balance-billing charges, and Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
health care this plan 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
1-888-256-3650 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
No. You can see the specialist you choose without a referral.
see a 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 * First Dollar coverage applies, see
$60/visit 50% coinsurance
injury or illness your Summary of Benefits for more
If you visit a health Specialist visit $95/visit 50% coinsurance information.
care provider's office You may have to pay for services that
or clinic Preventive care/screening No Charge; deductible does aren’t preventive. Ask your provider if
Not Covered
/immunization not apply the services needed are preventive.
Then check what your plan will pay for.
Lab & Path: 50%
Lab & Path: $40/visit;
coinsurance
deductible does not apply
X-Ray & Imaging: 50%
Diagnostic test (x-ray, blood X-Ray & Imaging: 40% The services listed are at a
coinsurance
work) coinsurance freestanding location.
Other Diagnostic
Other Diagnostic Examination:
Examination: 50%
40% coinsurance
If you have a test coinsurance
Outpatient Radiology Center:
Outpatient Radiology Center: 50% coinsurance
Preauthorization is required. Failure to
40% coinsurance Outpatient Hospital: 50%
Imaging (CT/PET scans, MRIs) obtain preauthorization may result in
Outpatient Hospital: 40% coinsurance subject to a
non-payment of benefits.
coinsurance benefit maximum of
$500/day
Retail: $17/prescription Retail: Not Covered
Tier 1
Mail Service: $51/prescription Mail Service: Not Covered
If you need drugs to Retail: 40% coinsurance up to
Preauthorization is required for select
treat your illness or $500/prescription
Retail: Not Covered drugs. Failure to obtain
condition Tier 2 Mail Service: 40%
Mail Service: Not Covered preauthorization may result in non-
More information about coinsurance up to
payment of benefits.
prescription drug $1,500/prescription
Retail: Covers up to a 30-day supply;
coverage is available at Retail: 40% coinsurance up to Mail Service: Covers up to a 90-day
blueshieldca.com/ $500/prescription
Retail: Not Covered supply.
formulary Tier 3 Mail Service: 40%
Mail Service: Not Covered
coinsurance up to
$1,500/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/MJ002189_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: 40% coinsurance Retail and Network Specialty
up to $500/prescription Retail: Not Covered Pharmacies: Covers up to a 30-day
Tier 4
Mail Service: 40% Mail Service: Not Covered supply; Specialty drugs must be
coinsurance up to obtained at a Network Specialty
$1,500/prescription Pharmacy.
Mail Service: Covers up to a 90-day
supply.
Ambulatory Surgery Center:
50% coinsurance subject to a
Ambulatory Surgery Center: benefit maximum of
Facility fee (e.g., ambulatory 40% coinsurance $300/day
If you have outpatient
surgery center) Outpatient Hospital: 40% Outpatient Hospital: 50% ----------------------None-----------------------
surgery
coinsurance coinsurance subject to a
benefit maximum of
$500/day
Physician/surgeon fees 40% coinsurance 50% coinsurance
Facility Fee: 40%
Facility Fee: 40% coinsurance
coinsurance
Emergency room care Physician Fee: No Charge; ----------------------None-----------------------
Physician Fee: No Charge;
deductible does not apply
deductible does not apply
If you need immediate
Emergency medical This payment is for emergency or
medical attention 40% coinsurance 40% coinsurance
transportation authorized transport.
* First Dollar coverage applies, see
Urgent care $60/visit 50% coinsurance your Summary of Benefits for more
information.
50% coinsurance subject to a Preauthorization is required. Failure to
If you have a hospital Facility fee (e.g., hospital room) 40% coinsurance benefit maximum of obtain preauthorization may result in
stay $500/day non-payment of benefits.
Physician/surgeon fees 40% coinsurance 50% coinsurance ----------------------None-----------------------

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/MJ002189_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)
Office Visit: $60/visit;
deductible does not apply
Office Visit: 50% coinsurance
Other Outpatient Services:
Other Outpatient Services:
40% coinsurance up to
50% coinsurance
$60/visit; deductible does not Preauthorization is required except for
Partial Hospitalization: 50%
apply office visits and office-based opioid
Outpatient services coinsurance subject to a
Partial Hospitalization: 40% treatment. Failure to obtain
benefit maximum of
coinsurance up to $60/visit; preauthorization may result in non-
$500/day
deductible does not apply payment of benefits.
Psychological Testing: 50%
If you need mental Psychological Testing: 40%
coinsurance
health, behavioral coinsurance up to $60/visit;
health, or substance deductible does not apply
abuse services Physician Inpatient Services:
50% coinsurance
Physician Inpatient Services: Hospital Services: 50%
40% coinsurance coinsurance subject to a
Preauthorization is required. Failure to
Hospital Services: 40% benefit maximum of
Inpatient services obtain preauthorization may result in
coinsurance $500/day
non-payment of benefits.
Residential Care: 40% Residential Care: 50%
coinsurance coinsurance subject to a
benefit maximum of
$500/day
No Charge; deductible does
Office visits 50% coinsurance
not apply
Childbirth/delivery professional
40% coinsurance 50% coinsurance
If you are pregnant services ----------------------None-----------------------
50% coinsurance subject to a
Childbirth/delivery facility
40% coinsurance benefit maximum of
services
$500/day
Preauthorization is required. Failure to
If you need help
obtain preauthorization may result in
recovering or have
Home health care 40% coinsurance Not Covered non-payment of benefits. Coverage
other special health
limited to 100 visits per member per
needs
Calendar Year.

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/MJ002189_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)
Office Visit: 50% coinsurance
Office Visit: $60/visit;
Outpatient Hospital: 50%
deductible does not apply
Rehabilitation services coinsurance subject to a
Outpatient Hospital: $60/visit;
benefit maximum of
deductible does not apply
$500/day
----------------------None-----------------------
Office Visit: 50% coinsurance
Office Visit: $60/visit;
Outpatient Hospital: 50%
deductible does not apply
Habilitation services coinsurance subject to a
Outpatient Hospital: $60/visit;
benefit maximum of
deductible does not apply
$500/day
Freestanding SNF: 50%
Preauthorization is required. Failure to
Freestanding SNF: 40% coinsurance
obtain preauthorization may result in
coinsurance Hospital-based SNF: 50%
Skilled nursing care non-payment of benefits. Coverage
Hospital-based SNF: 40% coinsurance subject to a
limited to 100 days per member per
coinsurance benefit maximum of
benefit period.
$500/day
Preauthorization is required. Failure to
Durable medical equipment 40% coinsurance 50% coinsurance obtain preauthorization may result in
non-payment of benefits.
Preauthorization is required except for
No Charge; deductible does pre-hospice consultation. Failure to
Hospice services Not Covered
not apply obtain preauthorization may result in
non-payment of benefits.
No Charge; deductible does All charges above $30; Coverage limited to one exam per
Children's eye exam
not apply deductible does not apply member per Calendar Year.
Coverage is limited to one eyeglass
frame and eyeglass lenses or contact
No Charge; deductible does All charges above $25;
If your child needs Children's glasses lenses instead of eyeglasses, up to the
not apply deductible does not apply
dental or eye care benefit per Calendar Year. The cost
listed is for Single Vision.
Coverage for prophylaxis services
No Charge; deductible does 10% coinsurance; deductible
Children's dental check-up (cleaning) is limited to once in a six
not apply does not apply
month period.

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/MJ002189_EOC.pdf. 5 of 8
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.)
• Non-emergency care when
• Chiropractic Care • Hearing Aids • Routine foot care
traveling outside the U.S.
• Cosmetic surgery • Infertility Treatment • Private-duty nursing • Weight loss programs
• Dental care (Adult) • Long-term care • Routine eye care (Adult)

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

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 1-888-256-3650. 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,
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? Not Applicable
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.

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/MJ002189_EOC.pdf. 6 of 8
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
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/MJ002189_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 $6,300 ◼ The plan’s overall deductible $6,300 ◼ The plan’s overall deductible $6,300
◼ Specialist copayment $95 ◼ Specialist copayment $95 ◼ Specialist copayment $95
◼ Hospital (facility) coinsurance 40% ◼ Hospital (facility) coinsurance 40% ◼ Hospital (facility) coinsurance 40%
◼ Other copayment $40 ◼ Other copayment $40 ◼ Other coinsurance 40%

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 $6,311 Deductibles $2,100 Deductibles $1,600
Copayments $500 Copayments $200 Copayments $200
Coinsurance $2,000 Coinsurance $1,200 Coinsurance $0
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 $8,871 The total Joe would pay is $3,520 The total Mia would pay is $1,800

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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Blue Shield of California is an independent member of the Blue Shield Association A52287GEN-NG_0122