Blue Shield of California
Access+ HMO® and TRIO HMO®
www.blueshieldca.com/federal
Customer service 800-880-8086
2019
A Health Maintenance Organization (High and Standard Option)
IMPORTANT
• Rates: Back Cover
• Changes for 2019: Page 16
• Summary of benefits: Page 88
This plan’s health coverage qualifies as a minimum essential
coverage and meets the minimum value standard for the benefits it
provides. See page 9 for details. This plan is accredited. See page
13.
Serving: Southern California
Enrollment in this plan is limited. You must live or
work in our Geographic service area to enroll. See page
14 for requirements.
Enrollment codes for this plan:
SI1 High Option Self Only
SI3 High Option Self Plus One
SI2 High Option Self and Family
SI4 Standard Self Only
SI6 Standard Self Plus One
SI5 Standard Self and Family
RI 73-574
Important Notice from Blue Shield of California About
Our Prescription Drug Coverage and Medicare
The Office of Personnel Management has determined that the Blue Shield of California’s prescription drug coverage is, on
average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants
and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for
prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late
enrollment as long as you keep your FEHB coverage.
However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will
coordinate benefits with Medicare.
Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.
Please be advised
If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s at least as good
as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every
month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug
coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this
higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next
Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.
Medicare’s Low Income Benefits
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.
Information regarding this program is available through the Social Security Administration (SSA) online at www.
socialsecurity.gov, or call the SSA at 800-772-1213 (TTY: 800-325-0778).
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these
places:
•Visit www.medicare.gov for personalized help
•Call 800-MEDICARE (800-633-4227), (TTY: 877-486-2048)
Table of Contents
Cover Page ....................................................................................................................................................................................1
Important Notice ...........................................................................................................................................................................1
Table of Contents ..........................................................................................................................................................................1
Introduction ...................................................................................................................................................................................4
Plain Language ..............................................................................................................................................................................4
Stop Health Care Fraud! ...............................................................................................................................................................4
Discrimination is Against the Law ................................................................................................................................................6
Preventing Medical Mistakes ........................................................................................................................................................7
FEHB Facts ...................................................................................................................................................................................9
No pre-existing condition limitation ...................................................................................................................................9
Minimum essential coverage (MEC) ..................................................................................................................................9
Minimum value standard ....................................................................................................................................................9
Where you can get information about enrolling in the FEHB Program .............................................................................9
Types of coverage available for you and your family .........................................................................................................9
Family member coverage ..................................................................................................................................................10
Children’s Equity Act ........................................................................................................................................................10
When benefits and premiums start ....................................................................................................................................11
When you retire .................................................................................................................................................................11
When FEHB coverage ends ..............................................................................................................................................11
Upon divorce .....................................................................................................................................................................12
Temporary Continuation of Coverage (TCC) ...................................................................................................................12
Converting to individual coverage ....................................................................................................................................12
Health Insurance Marketplace ..........................................................................................................................................12
Section 1. How This Plan Works ................................................................................................................................................13
Section 2. Changes for 2019 .......................................................................................................................................................16
Section 3. How You Get Care .....................................................................................................................................................17
Identification cards ............................................................................................................................................................17
Where you get covered care ..............................................................................................................................................17
Plan providers .........................................................................................................................................................17
Plan facilities ...........................................................................................................................................................17
What you must do to get covered care ..............................................................................................................................17
Primary care ............................................................................................................................................................17
Specialty care ..........................................................................................................................................................17
Second Opinions .....................................................................................................................................................19
Urgent Care .............................................................................................................................................................19
Hospital Care ..........................................................................................................................................................19
If you are hospitalized when your enrollment begins .............................................................................................19
You need prior Plan approval for certain services ............................................................................................................20
Inpatient hospital admission ...................................................................................................................................20
Other services ..........................................................................................................................................................20
How to request precertification for an admission or get prior authorization for Other services ......................................20
Non-urgent care claims ...........................................................................................................................................20
Urgent care claims ..................................................................................................................................................21
Concurrent care claims ...........................................................................................................................................21
Emergency inpatient admission ..............................................................................................................................21
If your treatment needs to be extended ...................................................................................................................21
1 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Table of Contents
Circumstances beyond our control ....................................................................................................................................21
If you disagree with our pre-service claim decision .........................................................................................................22
To reconsider a non-urgent care claim ....................................................................................................................22
To reconsider an urgent care claim .........................................................................................................................22
To file an appeal with OPM ....................................................................................................................................22
Section 4. Your Costs for Covered Services ...............................................................................................................................23
Cost-sharing ......................................................................................................................................................................23
Copayments .......................................................................................................................................................................23
Coinsurance .......................................................................................................................................................................23
Your catastrophic protection out-of-pocket maximum .....................................................................................................23
Carryover ..........................................................................................................................................................................23
When Government facilities bill us ..................................................................................................................................24
Section 5. High and Standard Option Benefits Overview ..........................................................................................................25
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals ............................27
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals ........................41
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................48
Section 5(d). Emergency Services/Accidents .............................................................................................................................51
Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................53
Section 5(f). Prescription Drug Benefits .....................................................................................................................................56
Section 5(g). Dental Benefits ......................................................................................................................................................61
Section 5(h). Wellness and Other Special Features .....................................................................................................................62
Non-FEHB benefits available to Plan members .........................................................................................................................67
Section 6. General Exclusions – Services, Drugs, and Supplies We Do not Cover ....................................................................68
Section 7. Filing a Claim for Covered Services .........................................................................................................................69
Section 8. The Disputed Claims Process .....................................................................................................................................71
Section 9. Coordinating Benefits with Medicare and Other Coverage .......................................................................................74
When you have other health coverage ..............................................................................................................................74
TRICARE and CHAMPVA ....................................................................................................................................74
Workers’ Compensation ..........................................................................................................................................74
Medicaid .................................................................................................................................................................74
When other Government agencies are responsible for your care .....................................................................................74
When others are responsible for injuries ...........................................................................................................................74
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage ..........................................75
Clinical trials .....................................................................................................................................................................75
When you have Medicare .................................................................................................................................................75
What is Medicare? ............................................................................................................................................................75
Should I enroll in Medicare? .............................................................................................................................................76
The Original Medicare Plan (Part A or Part B) .................................................................................................................77
Tell us about your Medicare coverage ....................................................................................................................78
Medicare Advantage (Part C) ............................................................................................................................................79
Medicare prescription drug coverage (Part D) ..................................................................................................................79
Section 10. Definitions of Terms We Use in This Brochure .......................................................................................................81
Section 11. Other Federal Programs ...........................................................................................................................................84
Important information about four Federal programs that complement the FEHB Program .............................................84
What is an FSA? ...............................................................................................................................................................84
Where can I get more information about FSAFEDS? ............................................................................................85
Important Information .......................................................................................................................................................85
Dental Insurance ...............................................................................................................................................................85
Vision Insurance ................................................................................................................................................................85
2 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Table of Contents
Additional Information .....................................................................................................................................................85
How do I enroll? ...............................................................................................................................................................85
It's important protection ....................................................................................................................................................86
Peace of Mind for You and Your Family ...........................................................................................................................86
Index ............................................................................................................................................................................................87
Summary of Benefits for Access+ HMO and TRIO HMO - 2019 .............................................................................................88
2019 Rate Information for Blue Shield of California Access+ HMO and TRIO HMO .............................................................94
3 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Table of Contents
Introduction
This brochure describes the benefits of Blue Shield of California Access+ HMO (High Option) and TRIO HMO (Standard
Option) under our contract (CS 2639) with the United States Office of Personnel Management (OPM), as authorized by the
Federal Employees Health Benefits law. This plan is underwritten by Blue Shield of California. Customer service may
be reached at 800-880-8086 or through our website: www.blueshieldca.com/federal . The address for Blue Shield of
California administrative offices is:
Blue Shield of California
50 Beale Street
San Francisco, CA 94105-1808
This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One
or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2019, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2019, and changes are
summarized on page 15. Rates are shown at the end of this brochure.
Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable
Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at
www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the
individual requirement for MEC.
The ACA establishes a minimum value for the standard of benefits of a health plan. The minimum value standard is 60%
(actuarial value). The health coverage of this plan meets the minimum value standard for the benefits the plan provides.
Plain Language
All FEHB brochures are written in plain language to make them easy to understand. Here are some examples,
•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member;
"we" means Blue Shield of California
.
•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States
Office of Personnel Management. If we use others, we tell you what they mean.
•Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program
premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless
of the agency that employs you or from which you retired.
Protect Yourself From Fraud - Here are some things you can do to prevent fraud:
•Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your health
care providers, authorized health benefits plan, or OPM representative.
•Let only the appropriate medical professionals review your medical record or recommend services.
•Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.
4 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Introduction/Plain Language/Advisory
•Carefully review explanations of benefits (EOBs) statements that you receive from us.
•Periodically review your claim history for accuracy to ensure we have not billed for services you did not receive.
•Please review your claims history periodically for accuracy to ensure services are not being billed to your accounts that
were never rendered.
•Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call us at 800-880-8086 and explain the situation.
- If we do not resolve the issue:
CALL - THE HEALTH CARE FRAUD HOTLINE
887-499-7295
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/
The online reporting form is the desired method of reporting fraud in order to ensure and a quicker response time.
You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC20415-1100
•Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
- Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26)
•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with
your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under
Temporary Continuation of Coverage (TCC).
•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and
your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to
obtaining service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when
you are no longer eligible.
•If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service)
and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not
paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using
health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family
member is no longer eligible to use your health insurance coverage.
5 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Introduction/Plain Language/Advisory
Discrimination is Against the Law
Blue Shield of California complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights
Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, Blue Shield of California does not
discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.
If a carrier is a covered entity, it's members may file a 1557 complaint with HHS Office of Civil Rights, OPM, or FEHB
Program carriers. For purposes of filing a complaint with OPM, covered carriers should use the following:
You may file a 1557 complaint with the HHS Office of Civil Rights, an FEHB Program carrier, or OPM. You may file a civil
rights complaint with the OPM by mail at:
Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
Attention: Assistant Director
1900 E Street NW Suite 3400-S
Washington, D.C. 20415-3610
6 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Preventing Medical Mistakes
Medical mistakes continue to be a significant cause of preventable death within the United States. While death is the most
tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost
of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical
mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your
family members by learning more about and understanding your risks. Take these simple steps:
1. Ask questions if you have doubts or concerns.
•Ask questions and make sure you understand the answers.
•Choose a doctor with whom you feel comfortable talking.
•Take a relative or friend with you to help you take notes, ask questions, and understand answers.
2. Keep and bring a list of all the medications you take.
•Bring the actual medication or give your doctor and pharmacist a list of all the medicines and dosage that you take,
including non-prescription (over-the-counter) medications and nutritional supplements.
•Tell your doctor and pharmacist about any drug, food, and other allergies you have such as to latex.
•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your
doctor or pharmacist says.
•Make sure your medication is what the doctor ordered. Ask your pharmacist about the medication if it looks different than
you expected.
•Read the label and patient package insert when you get your medication, including all warnings and instructions.
•Know how to use your medication. Especially note the times and conditions when your medication should and should not
be taken.
•Contact your doctor or pharmacist if you have any questions.
•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing
from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.
3. Get the results of any test or procedure.
•Ask when and how you will get the results of test or procedures. Will it be in person, by phone, mail, through the Plan or
Provider's portal?
•Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your
results.
•Ask what the results mean for your care.
4. Talk to your doctor about which hospital or clinic is best for your health needs.
•Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one
hospital to or clinic choose from to get the health care you need.
•Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.
5. Make sure you understand what will happen if you need surgery.
•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
•Ask your doctor, “Who will manage my care when I am in the hospital?”
•Ask your surgeon:
- "Exactly what will you be doing?"
7 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Introduction/Plain Language/Advisory
- "About how long will it take?"
- "What will happen after surgery?"
- "How can I expect to feel during recovery?"
•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or
nutritional supplements you are taking.
Patient Safety Links
For more information on patient safety, please visit:
- www.jointcommission.org/speakup.aspx The Joint Commission's Speak Up TM patient safety program.
- www.jointcommission.org/topics/patient_safety.aspx The Joint Commission helps healthcare organizations to improve
the quality and safety of the care they deliver.
- www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging
list of topics not only to inform consumers about patient safety but to help choose quality health care providers and
improve the quality of care you receive.
- www.npsf.org The National Safety Foundation has information on how to ensure safer health care for you and your
family.
- www.bemedwise.org The National Council on Patient Information and Education is dedicated to improving
communication about the safe, appropriate use medication.
- www.leapfroggroup.org The Leapfrog Group is active in promoting safe practices in hospital care.
- www.ahqa.org The American Health Quality Association represents organizations and health care professionals working
to improve patient safety.
Preventable Healthcare Acquired Conditions ("Never Events")
When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries,
infections or other serious conditions that occur during the course of your stay. Although some of these complications may
not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had
taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences
for patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and
errors are sometimes called "Never Events" or "Serious Reportable Events".
We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as
certain infections, severe bedsores and fractures; and reduce medical errors that should never happen. When a Never Event
occurs, neither your FEHB plan nor you will incur cost to correct the medical error.
Blue Shield expects all participating hospitals to take proper precautions to prevent unnecessary and avoidable injuries and or
illnesses. As part of Blue Shield's commitment to improving the quality of care available to members, Blue Shield has
adopted payment policies that encourage hospitals to reduce the incidence of certain hospital-acquired conditions (HACs)
and "Never Events". Blue Shield will not pay or otherwise reimburse participating hospitals for inpatient services related to
those HACs and "Never Events" listed on Provider Connection at https://www.blueshieldca.com/provider/claims/policies-
guidelines/payment-rules.sp.
8 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Introduction/Plain Language/Advisory
FEHB Facts
Coverage information
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan
solely because you had the condition before you enrolled.
• No pre-
existing
condition
limitation
Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient
Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please
visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-
the-Individual-Shared-Responsibility-Provision for more information on the individual
requirement for MEC.
• Minimum
essential
coverage
(MEC)
Our health coverage meets the minimum value standard of 60% established by the ACA. This
means that we provide benefits to cover at least 60% of the total allowed costs of essential health
benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined
as explained in this brochure.
• Minimum
value
standard
See www.opm.gov/healthcare-insurance for enrollment information as well as:
• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems
Also, your employing or retirement office can answer your questions, and give you brochures for
other plans and other materials you need to make an informed decision about your FEHB coverage.
These materials tell you:
• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter
military service, or retire
• What happen when your enrollment ends
• When the next Open Season for enrollment begins
We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment
status without information from your employing or retirement office. For information on your
premium deductions, you must also contact your employing or retirement office.
• Where you
can get
information
about
enrolling in
the FEHB
Program
Self Only coverage is for you alone. Self Plus One coverage is an enrollment that covers you and
one eligible family member. Self and Family coverage is for you, and one eligible family
member, or your spouse, and your dependent children under age 26, including any foster children
authorized for coverage by your employing agency or retirement office. Under certain
circumstances, you may also continue coverage for a disabled child 26 years of age or older who is
incapable of self-support.
If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family
enrollment if you marry, give birth, or add a child to your family. You may change your enrollment
31 days before to 60 days after that event. The Self and Family and Self Plus One enrollment
begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the
first day of the pay period that begins after your employing office receives your enrollment form.
Benefits will not be available to your spouse until you are married.
• Types of
coverage
available for
you and your
family
9 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
FEHB Facts
Your employing or retirement office will not notify you when a family member is no longer
eligible to receive benefits, nor will we. Please tell us immediately of changes in family member
status including your marriage, divorce, annulment, or when your child reaches age 26.
If you or one of your family members is enrolled in one FEHB plan, you or they cannot be
not be enrolled in or covered as a family member by another enrollee in another FEHB plan.
If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child -
outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program,
change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website
at www.opm.gov/heathcare-insurance/life-events. If you need assistance, please contact your
employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.
Family members covered under your Self and Family enrollment are your spouse (including a
valid common law marriage) and children as described in the chart below. A Self Plus One
enrollment covers you and your spouse, or one other eligible family member as described in the
chart below.
ChildrenCoverage
Natural children, adopted children, and
stepchildren
Natural, adopted children and stepchildren are
covered until their 26
th
birthday.
Foster children Foster children are eligible for coverage until
their 26
th
birthday if you provide documentation
of your regular and substantial support of the
child and sign a certification stating that your
foster child meets all the requirements. Contact
your human resources office or retirement
system for additional information.
Children incapable of self-support Children who are incapable of self-support
because of a mental or physical disability that
began before age 26 are eligible to continue
coverage. Contact your human resources office
or retirement system for additional information.
Married children Married children (but NOT their spouse or their
own children) are covered until their 26th
birthday.
Children with or eligible for employer-provided
health insurance
Children who are eligible for or have their own
employer-provided health insurance are covered
until their 26th birthday.
Newborns of covered children are insured only for routine nursery care during the covered portion
of the mother's maternity stay.
You can find additional information at www.opm.gov/healthcare-insurance.
• Family
member
coverage
OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This
law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB
Program, if you are an employee subject to a court or administrative order requiring you to provide
health benefits for your child(ren).
If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health
plan that provides full benefits in the area where your children live or provide documentation to
your employing office that you have obtained other health benefits coverage for your children. If
you do not do so, your employing office will enroll you involuntarily as follows:
• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self
and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined
by OPM.
• Children’s
Equity Act
10 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
FEHB Facts
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area
where your children live, your employing office will change your enrollment to Self Plus One
or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your
employing office will change your enrollment to Self Plus One or Self and Family, as
appropriate, in the lowest-cost nationwide plan option as determined by OPM.
As long as the court/administrative order is in effect, and you have at least one child identified in
the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change
to Self Only, or change to a plan that does not serve the area in which your children live, unless
you provide documentation that you have other coverage for the children.
If the court/administrative order is still in effect when you retire, and you have at least one child
still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if
eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does
not serve the area in which your children live as long as the court/administrative order is in effect.
Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than
one child. Contact your employing office for further information.
The benefits in this brochure are effective January 1. If you joined this Plan during Open Season,
your coverage begins on the first day of your first pay period that starts on or after January 1. If
you changed plans or plan options during Open Season and you receive care between
January 1 and the effective date of coverage under your new plan or option, your claims will
be paid according to the 2019 benefits of your old plan or option. However, if your old plan
left the FEHB Program at the end of the year, you are covered under that plan’s 2018 benefits until
the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin
on January 1. If you joined at any other time during the year, your employing office will tell you
the effective date of coverage.
If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated
from Federal service) and premiums are not paid, you will be responsible for all benefits paid
during the period in which premiums were not paid. You may be billed for services received
directly from the provider. You may be billed for services received directly from your provider.
You may be prosecuted for fraud for knowingly using health insurance benefits for which you have
not paid premiums. It is your responsibility to know when you or a family member are no longer
eligible to use your health insurance coverage.
• When
benefits and
premiums
start
When you retire, you can usually stay in the FEHB Program. Generally, you must have been
enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet
this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation
of Coverage (TCC).
• When you
retire
When you lose benefits
You will receive an additional 31 days of coverage, for no additional premium, when:
• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.
Any person covered under the 31 day extension of coverage who is confined in a hospital or
other institution for care or treatment on the 31
st
day of the temporary extension is entitled to
continuation of the benefits of the Plan during the continuance of the confinement but not
beyond the 60
th
day after the end of the 31 day temporary extension.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC),
or a conversion policy (a non-FEHB individual policy).
• When FEHB
coverage ends
11 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
FEHB Facts
If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits
under your former spouse’s enrollment. This is the case even when the court has ordered your
former spouse to provide health coverage for you. However, you may be eligible for your own
FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage
(TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s
employing or retirement office to get information about your coverage choices. You can also
visit OPM’s Web site,
www.opm.gov/healthcare-insurance/healthcare/plan-information/guides .
• Upon divorce
If you leave Federal service, Tribal employment, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for Temporary Continuation of Coverage
(TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For
example, you can receive TCC if you are not able to continue your FEHB enrollment after you
retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn
26, etc.
You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC
,
from your employing or retirement
office or from www.opm.gov/healthcare-insurance . It explains what you have to do to enroll.
Alternatively, you can buy coverage through the Health Insurance Marketplace where,
depending on your income, you could be eligible for a new kind of tax credit that lowers your
monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium,
deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if
you qualify for coverage under another group health plan (such as your spouse's plan), you may
be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program
coverage.
We also want to inform you that the Patient Protection and Affordable Care Act (ACA) did not
eliminate TCC or change TCC rules.
• Temporary
Continuation of
Coverage
(TCC)
You may convert to a non-FEHB individual policy if:
• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or
did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal or Tribal service, your employing office will notify you of your right to
convert. You must contact us in writing within 31 days after you receive this notice. However, if
you are a family member who is losing coverage, the employing or retirement office will not
notify you. You must contact us in writing within 31 days after you are no longer eligible for
coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not
have to answer questions about your health, waiting period will not be imposed, and your
coverage will not be limited due to pre-existing conditions.
When you contact us, we will assist you in obtaining information about health benefits coverage
inside or outside the ACA's Health Insurance Marketplace in your state. For assistance in finding
coverage, please contact us at (800) 880-8086 or visit our website at http://www.blueshieldca.
com/federal.
• Converting to
individual
coverage
If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace,
please visit www.HealthCare.gov.This is a website provided by the U.S. Department of Health
and Human Services that provides up-to-date information on the Marketplace.
• Health Insurance
Marketplace
12 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
FEHB Facts
Section 1. How This Plan Works
This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan
operations and/or care management meet nationally recognized standards. Blue Shield of California holds the following
accreditations: NCQA and the local plans and vendors that support Blue Shield of California hold accreditation from
NCQA. To learn more about this plan's accreditation(s), please visit the following websites: reportcards.ncqa.org. We require
you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your
health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our
most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any
course of treatment.
This HMO consists of a Standard and a High Option:
Access+ HMO is our High Option. It is a traditional Health Maintenance Organization (HMO) and offers services through
a wide range of medical groups and providers.
TRIO HMO is our Standard Option. It is an Accountable Care Organization (ACO). An ACO is a network of doctors and
hospitals that share financial and medical responsibility for providing coordinated care. TRIO HMO is available only in San
Diego County and is contracted exclusively with Scripps Medical Group. You may only use Scripps Medical Group
providers and facilities. There are no benefits offered outside of Scripps Medical Group, see page 14 to see the service area
for our Standard Option.
As a TRIO HMO member, you will also receive the Shield Concierge service benefit. Shield Concierge consists of a team of
registered nurses, health coaches, social workers, pharmacy technicians, pharmacists, and customer service representatives
working together to help you with receiving and coordinating care without interruption.
All benefits and copays are the same for both High (Access+ HMO) and Standard (TRIO HMO) Options. (See Section 5 for
Benefits and Copays).
When you receive services from Plan providers, you will not have to submit claim forms except for your annual eye exam.
You only pay the copayments and coinsurance described in this brochure. When you receive emergency services from non-
Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You
cannot change plans because a provider leaves our plan. We cannot guarantee that any one physician, hospital, or
other provider will be available and/or remain under contract with us.
How we pay providers
We contract with physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your cost-sharing (co-payments, coinsurance,
deductibles, and non-covered services and supplies).
Your Rights and Responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us,
our networks, and our providers. OPM’s FEHB Web site (www.opm.gov/insure) lists the specific types of information that
we must make available to you. Some of the required information is listed below.
•Years in existence
•Profit status
You are entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can
view the complete list of these rights and responsibilities by viewing our website www.blueshieldca.com/federal. You can
also contact us to request that we mail a copy to you.
Corporate Form – Blue Shield of California is a not-for-profit corporation that was founded in 1939.
13 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 1
Fiscal Solvency – Blue Shield of California meets or exceeds California Department of Managed Health Care standards for
fiscal solvency, confidentiality of medical records and transfer of medical records.
“Gag Clauses” – A “gag clause” is when a physician does not disclose all treatment options based on cost considerations. You
have the right to have a clear understanding of the medical condition and any proposed appropriate necessary treatment
alternatives, including available success/outcomes information, regardless of cost or benefit coverage, so you can make an
informed decision before receiving treatment.
Medical Records – Access+ HMO and TRIO HMO members have the right, both under state law and Blue Shield of
California policy, to review, summarize and copy their own medical records. Members can request and will receive
amendments to their medical records as they are made.
State Licensing – Access+ HMO and TRIO HMO have been licensed by the State of California since 1978.
If you want more information about us, call us at 800-880-8086, or write to Blue Shield of California, P.O. Box 7168, San
Francisco, CA 94120-7168. You may also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims
information (including your prescription drug utilization) to any of your treating physicians and dispensing pharmacies.
By law, you have the right to access your personal health information (PHI). For more information regarding access to PHI,
visit our website at www.blueshieldca.com/federal. You can also contact us to request that we mail a copy regarding access to
PHI.
Self-referral to specialty services
Access+ HMO and TRIO HMO allow you to arrange office visits with plan specialists in the same Medical Group or IPA as
your primary care physician without a referral. For more information about Self-referral to specialty services please see page
62.
Service Area
To enroll in these plans, you must live in or work in our service area. This is where our providers practice. Our service areas
are:
ACCESS+ HMO
Southern California full counties:
Fresno, Kings, Los Angeles, San Diego, Orange, Riverside, Santa Barbara, Tulare, and Ventura counties, California.
Partial counties: Kern and San Bernardino counties, California. The following ZIP codes are those excluded in these partial
counties:
KERN:
93527, 93528, 93554, 93555, 93556, 93516
SAN BERNARDINO:
92242, 92280 and 92363
TRIO HMO
This plan option is offered only in part of San Diego county.
Partial county: San Diego county, California. The following ZIP codes are those excluded in this partial county:
91934, 92004, 92066, 92070, 92086
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will
normally pay only for emergency or urgent care. We will not pay for any other health care service, except those that are
specifically listed on page 67 under the heading “Medical Care for Vacations, Business Travel and College Students.”
14 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 1
If you or a covered family member move outside the service area, you can enroll in another plan. If your dependents live out
of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan
or an HMO like ours that has agreements with affiliates in other states. See page 67 for details about our HMO medical care
available for vacations, business travel and college students coverage. If you or a family member move, you do not have to
wait until Open Season to change plans. Contact your employing agency or retirement office.
15 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 1
Section 2. Changes for 2019
Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Changes to this Plan
•We are now offering a new Standard Option ACO HMO. The Standard Option, known as TRIO HMO, is available only in
San Diego County and utilizes Scripps Health Network physicians and hospitals. The services covered are identical as the
High Option Access+HMO. Please see Section 1 for additional information about our ACO HMO, and the benefits
sections for specific services and copays. (see page 27)
•The Well Being Assessment is now called the Health Risk Assessment. There has been no change to this benefit.
16 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 2
Section 3. How You Get Care
We will send you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your electronic enrollment system (such as Employee
Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at (800) 880-8086. You may also
request cards through our website www.blueshieldca.com
Identification cards
You get care from “Plan providers” and “Plan facilities.” You will only pay co-payments
and/or coinsurance, and you will not have to file claims, except for your annual eye
examination.
Where you get covered
care
Plan providers are physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. All Plan providers are
credentialed, according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is
also on our website, www.blueshieldca.com/federal.
• Plan providers
Plan facilities are hospitals and other facilities in our service area that we contract with to
provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our website, www.blueshieldca.com/federal.
• Plan facilities
It depends on the type of care you need. First, you and each family member must choose a
primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. You must complete a Primary Care
Physician Selection Form.
What you must do to get
covered care
Your primary care physician can be a general practitioner, family practitioner, internist,
pediatrician, or an OB/GYN. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician or IPA/
Medical Group leaves the Plan, call us at (800) 880-8086. We will help you select a new
one.
• Primary care
Your primary care physician will refer you to a specialist for needed care. When you
receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral.
The exceptions to this are:
1. for true medical emergencies;
2. when another physician is on call for your physician;
3. when you self-refer to an Access+ HMO or TRIO HMO participating specialist (not
applicable to infertility, emergency and urgent care and allergy services; mental health
and substance use Access+ HMO or TRIO HMO specialist care must be provided by a
provider in Blue Shield's Mental Health Services Administrator (MHSA) network.
(see page 53 for details.);
4. OB/GYN services provided by an obstetrician/gynecologist or family practitioner
within the same IPA/Medical Group as your primary care physician.
• Specialty care
17 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 3
In all other instances, referral to a specialist is done at the primary care physician’s
direction; if non-Plan specialists or consultants are required, the primary care physician
will arrange appropriate referrals.
Here are other things you should know about specialty care:
• If you need to see a specialist frequently because of a chronic, complex or serious
medical condition, your primary care physician will develop a treatment plan with you
that allows an adequate number of direct access visits with that specialist. Your
primary care physician will use our criteria when creating your treatment plan.
• Your primary care physician will create your treatment plan. The physician may have
to get an authorization or approval from us beforehand. If you are seeing a specialist
when you enroll in our Plan, talk to your primary care physician. If he or she decides
to refer you to a specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist
who does. We will not pay for you to see a specialist who does not participate with our
Plan, unless your primary care physician refers you to a non-Plan specialist for a
second opinion.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care
physician, who will arrange for you to see another specialist. You may receive services
from your current specialist until we can make arrangements for you to see someone
else.
• If you have a chronic or disabling condition and lose access to your specialist because
we:
- terminate our contract with your specialist for other than cause;
- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll
in another FEHB plan; or
- reduce our service area and you enroll in another FEHB plan;
You may be able to continue seeing your specialist for up to 90 days or when clinically
appropriate after you receive notice of the change. Contact us or, if we drop out of the
program, contact your new Plan.
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days. Contact us to coordinate
care for these types of cases.
If you are a new Blue Shield of California Access+ HMO or TRIO HMO member and are
currently receiving treatment for a qualifying medical condition from a provider who is
not in our network, you may be eligible to complete treatment of your condition with the
provider. Or, if you are an existing member and are currently receiving treatment for a
qualifying medical condition from a provider who is leaving our network, you may be
eligible to complete treatment of your condition with the provider. In order to receive
more information about continuity of care and qualifying medical conditions and
situations, please contact us at (800) 880-8086 and we will assist you.
Continuity of care is also available if you are currently receiving services for a serious
mental health condition. To obtain further information, please contact our Mental Health
Services Administrator (MHSA) directly by calling their Member Services at (877)
263-9952.
18 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 3
If there is a question about your diagnosis or if additional information concerning your
condition would be helpful in determining the most appropriate plan of treatment, your
primary care physician will, upon request, refer you to another physician for a second
medical opinion. If you are requesting a second opinion about care you received from
your primary care physician, a physician within the same Medical Group/IPA as your
primary care physician will provide the second opinion. If you are requesting a second
opinion about care received from a specialist, any Plan specialist of the same equivalent
specialty may provide the second opinion. We must authorize all second opinion
consultations.
• Second Opinions
We have made arrangements for an added benefit for you and your family for your urgent
care needs when you or your family are temporarily traveling outside of your primary care
physician’s service area.
When you are traveling outside of California, you can get urgent care services across the
country and around the world through the BlueCard® Program. While traveling within the
United States, you can locate a BlueCard provider any time by calling 1-800-810-BLUE
(2583) or by going to www.blueshieldca.com/federal. If you are traveling outside of the
United States you can call (804) 673-1177 collect 24 hours a day to locate BlueCard
Worldwide® Network Provider.
If you need urgent care while in your primary care physician's service area, you must first
call your primary care physician. If your primary care physician (or your assigned medical
group) has provided instructions to seek in-area urgent care at a local urgent care clinic
you may do so without calling your primary care physician first.
When you are traveling within California but you are outside of your primary care
physician’s service area, you should call Blue Shield Member Services at (800) 880-8086
for assistance in receiving Urgent Care through a Blue Shield of California Plan provider.
You may also locate a Plan provider by visiting our web site at www.blueshieldca.com/
federal. Remember that when you are within your primary care physician’s service area,
Urgent Care must be provided or authorized by your primary care physician just like all
other non-emergency services of the Plan.
• Urgent Care
Your Plan primary care physician or specialist will make necessary hospital arrangements
and supervise your care. This includes admission to a skilled nursing or other type of
facility.
• Hospital Care
We pay for covered services from the effective date of your enrollment. However, if you
are in the hospital when your enrollment in our plan begins, call our member service
department immediately at (800) 880-8086. If you are new to the FEHB Program, we will
arrange for you to receive care and provide benefits for your covered services while you
are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB Plan to us, your former Plan will pay for the hospital
stay until:
• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former Plan run out; or
• the 92
nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your Plan
terminates participation in the FEHB Program in whole or in part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such case,
the hospitalized family member's benefits under the new benefit Plan begin on the
effective date of enrollment.
• If you are hospitalized
when your enrollment
begins
19 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 3
The Plan provides coverage for Medically Necessary services for the treatment of gender
dysphoria. This includes medical and mental health benefits, as well as benefits for
surgical procedures related to gender reassignment with prior authorization. Travel and
lodging expenses may also be covered when necessary to obtain Covered Services and
authorized in advance by Blue Shield of California.
• Gender dysphoria
Since your primary care physician arranges most referrals to specialists and inpatient
hospitalization, the pre-service claim approval process only applies to care shown under
Other services
.
You need prior Plan
approval for certain
services
Precertification is the process by which – prior to your inpatient hospital admission – we
evaluate the medical necessity of your proposed stay and the number of days required to
treat your condition.
• Inpatient hospital
admission
Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain prior approval from us. Before giving
approval, we consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
Your primary care physician must obtain a preauthorization from us for: (1) selected drugs
and drug dosages which require prior authorization for medical necessity, including most
specialty drugs, (2) growth hormone therapy (GHT) (3) organ transplants (4) bone marrow
transplants (5) cancer clinical trials (6) skilled nursing facility care and hospice care and
(7) mental health and substance misuse services.
Refer to Section 5(b) for the preauthorization process for organ and bone marrow
transplants.
Refer to Section 5(c) for preauthorization process for extended care/skilled nursing care
facility and hospice care benefits.
Refer to Section 5(e) for preauthorization process for mental health and substance misuse
benefits.
Refer to Section 5(f) for preauthorization process for drugs and drug dosages including
home self-administered injectable drugs.
• Other services
First, your physician, your hospital, you, or your representative, must call us at (800)
880-8086 before admission or services requiring prior authorization are rendered.
Next, provide the following information:
• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay
How to request
precertification for an
admission or get prior
authorization for Other
services
For non-urgent care claims, we will tell the physician and/or hospital the number of
approved inpatient days, or the care that we approve for other services that must have
prior authorization. We will make our decision within 15 days of receipt of the pre-
service claim. If matters beyond our control require an extension of time, we may take up
to an additional 15 days for review and we will notify you of the need for an extension of
time before the end of the original 15-day period. Our notice will include the
circumstances underlying the request for the extension and the date when a decision is
expected.
• Non-urgent care
claims
20 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 3
If we need an extension because we have not received necessary information from you,
our notice will describe the specific information required and we will allow you up to 60
days from the receipt of the notice to provide the information.
If you have an urgent care claim (i.e., when waiting for the regular time limit for your
medical care or treatment could seriously jeopardize your life, health, or ability to regain
maximum function, or in the opinion of a physician with knowledge of your medical
condition, would subject you to severe pain that cannot be adequately managed without
this care or treatment), we will expedite our review and notify you of our decision within
72 hours. If you request that we review your claim as an urgent care claim, we will
review the documentation you provide and decide whether or not it is an urgent care claim
by applying the judgment of a prudent layperson that possesses an average knowledge of
health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we
receive the claim to let you know what information we need to complete our review of the
claim. You will then have up to 48 hours to provide the required information. We will
make our decision on the claim within 48 hours of (1) the time we received the additional
information or (2) the end of time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with
written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us
and OPM. Please let us know that you would like a simultaneous review of your urgent
care claim by OPM either in writing at the time you appeal our initial decision, or by
calling us at (800) 880-8086. You may also call OPM’s Health Insurance II at (202)
606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We
will cooperate with OPM so they can quickly review your claim on appeal. In addition, if
you did not indicate that your claim was a claim for urgent care, call us at (800) 880-8086.
If it is determined that your claim is an urgent care claim, we will expedite our review (if
we have not yet responded to your claim).
• Urgent care claims
A concurrent care claim involves care provided over a period of time or over a number of
treatments. We will treat any reduction or termination of our pre-approved course of
treatment before the end of the approved period of time or number of treatments as an
appealable decision. This does not include reduction or termination due to benefit changes
or if your enrollment ends. If we believe a reduction or termination is warranted, we will
allow you sufficient time to appeal and obtain a decision from us before the reduction or
termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to
the expiration of the approved time period and this is also an urgent care claim, then we
will make a decision within 24 hours after we receive the claim.
• Concurrent care
claims
If you have an emergency admission due to a condition that you reasonably believe puts
your life in danger or could cause serious damage to bodily function, you, your
representative, the physician, or the hospital must telephone us within two business days
following the day of the emergency admission, even if you have been discharged from the
hospital.
• Emergency inpatient
admission
If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, we will make
a decision within 24 hours after we receive the claim.
• If your treatment
needs to be extended
Under certain extraordinary circumstances, such as natural disasters, we may have to
delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Circumstances beyond
our control
21 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 3
If you have a pre-service claim and you do not agree with our decision regarding
precertification of an inpatient admission or prior approval of other services, you may
request a review in accord with the procedures detailed below.
If you have already received the service, supply, or treatment, then you have a post-
service claim and must follow the entire disputed claims process detailed in Section 8.
If you disagree with our
pre-service claim decision
Within 6 months of our initial decision, you may ask us in writing to reconsider our initial
decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this
brochure.
In the case of a pre-service claim and subject to a request for additional information, we
have 30 days from the date we receive your written request for reconsideration to
1. Pre-certify your hospital stay or, if applicable, arrange for the health care provider to
give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our
request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We will base our decision on the information we already
have. We will write to you with our decision.
3. Write to you and maintain our denial.
• To reconsider a non-
urgent care claim
In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial
decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of
the disputed claims process detailed in Section 8 of this brochure.
Unless we request additional information, we will notify you of our decision within 72
hours after receipt of your reconsideration request. We will expedite the review process,
which allows oral or written requests for appeals and the exchange of information by
telephone, electronic mail, facsimile, or other expeditious methods.
• To reconsider an
urgent care claim
After we reconsider your pre-service claim, if you do not agree with our decision, you
may ask OPM to review it by following Step 3 of the disputed claims process detailed in
Section 8 of this brochure.
• To file an appeal with
OPM
22 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 3
Section 4. Your Costs for Covered Services
This is what you will pay out-of-pocket for covered care:
Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,
coinsurance, and copayments) for the covered care you receive.
Cost-sharing
A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive certain services.
Example: When you see your primary care physician, you pay a copayment of $20 per
office visit.
Copayments
Coinsurance is the percentage of our allowable fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services or durable
medical equipment.
Coinsurance
We do not have a calendar year deductible. Deductible
After your (co-payments and your coinsurance) total $3,000 for Self Only or $3,000 per
person for Self Plus One or $6,000 per Self and Family enrollment in any calendar year,
you do not have to pay any more for covered services. However, the following services do
not count toward your catastrophic protection out-of-pocket maximum, and you must
continue to pay co-payments and/or coinsurance for these services:
1. infertility services
Be sure to keep accurate records of your co-payments and coinsurance since you are
responsible for informing us when you reach the maximum. You must notify Blue Shield
Member Services in writing when you feel that your catastrophic protection out-of-pocket
maximum has been reached. At that time, you must submit complete and accurate records
to us substantiating your copay and/or coinsurance expenditures. Receipts and/or
statements must include: name of patient, date of service and amount paid.
Send information to:
Blue Shield of California
Member Services
P.O. Box 272550
Chico, CA 95927
or
Fax: to 916-650-8780
For assistance call us at (800) 880-8086.
Your catastrophic
protection out-of-pocket
maximum
If you changed to this Plan during open season from a Plan with a catastrophic protection
benefit and the effective date of the change was after January 1, any expenses that would
have applied to that Plan’s catastrophic protection benefit during the prior year will be
covered by your old Plan if they are for care you received in January before your effective
date of coverage in this Plan. If you have already met your old Plan’s catastrophic
protection benefit level in full, it will continue to apply until the effective date of your
coverage in this Plan. If you have not met this expense level in full, your old Plan will first
apply your covered out-of-pocket expenses until the prior year’s catastrophic level is
reached and then apply the catastrophic protection benefit to covered out-of-pocket
expenses incurred from that point until the effective date of your coverage in this Plan.
Your old Plan will pay these covered expenses according to this year’s benefits; benefit
changes are effective January 1.
Carryover
23 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 4
Note: If you change options in this Plan during the year, we will credit the amount of
covered expenses already accumulated towards the catastrophic out-of-pocket limit of
your old option to the catastrophic protection limit of your new option.
Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian
Health Services are entitled to seek reimbursement from us for certain services and
supplies they provide to you or a family member. They may not seek more than their
governing laws allow. You may be responsible to pay for certain services and charges.
Contact the government facility directly for more information.
When Government
facilities bill us
24 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 4
Section 5. High and Standard Option Benefits Overview
High and Standard Option
This Plan offers both a High and Standard Option. Both benefit packages are described in Section 5. Make sure that you
review the benefits that are available under the option in which you are enrolled.
The High and Standard Option Section 5 is divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us (800)
880-8086 or at our Web site at www.blueshieldca.com/federal.
Each option offers unique features.
•High Option
•Standard Option
Section 5. High and Standard Option Benefits Overview ..........................................................................................................25
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals ............................27
Diagnostic and treatment services .....................................................................................................................................27
Teladoc ..............................................................................................................................................................................27
Lab, X-ray and other diagnostic tests ................................................................................................................................28
Preventive care, adult ........................................................................................................................................................28
Preventive care, children ...................................................................................................................................................30
Maternity care ...................................................................................................................................................................30
Family planning ................................................................................................................................................................31
Infertility services .............................................................................................................................................................32
Allergy care .......................................................................................................................................................................32
Treatment therapies ...........................................................................................................................................................32
Physical and occupational therapies .................................................................................................................................33
Speech therapy ..................................................................................................................................................................33
Hearing services (testing, treatment, and supplies) ...........................................................................................................33
Vision services (testing, treatment, and supplies) .............................................................................................................34
Foot care ............................................................................................................................................................................34
Orthopedic and prosthetic devices ....................................................................................................................................34
Durable medical equipment (DME) ..................................................................................................................................35
Home health services ........................................................................................................................................................36
Chiropractic/Alternative treatments ..................................................................................................................................37
Educational classes and programs .....................................................................................................................................37
Clinical trials .....................................................................................................................................................................39
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals ........................41
Surgical procedures ...........................................................................................................................................................41
Reconstructive surgery ......................................................................................................................................................42
Oral and maxillofacial surgery ..........................................................................................................................................43
Organ/tissue transplants ....................................................................................................................................................43
Anesthesia .........................................................................................................................................................................47
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................48
Inpatient hospital ...............................................................................................................................................................48
Outpatient hospital or ambulatory surgical center ............................................................................................................49
Extended care benefits/Skilled nursing care facility benefits ...........................................................................................49
Hospice care ......................................................................................................................................................................49
Ambulance ........................................................................................................................................................................50
25 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5
High and Standard Option
Section 5(d). Emergency Services/Accidents .............................................................................................................................51
Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................53
Routine outpatient mental health and substance misuse disorder benefits .......................................................................53
Non-routine outpatient mental health and substance misuse disorder benefits ................................................................53
Inpatient services ...............................................................................................................................................................54
Preauthorization ................................................................................................................................................................54
Out-of-Network mental health and substance misuse disorder benefits ...........................................................................55
Section 5(f). Prescription Drug Benefits .....................................................................................................................................56
Preventative Care medications to promote better health as recommended by ACA ........................................................57
Covered medications and supplies ....................................................................................................................................58
Section 5(g). Dental Benefits ......................................................................................................................................................61
Accidental injury benefit ...................................................................................................................................................61
Section 5(h). Wellness and Other Special Features .....................................................................................................................62
Feature ...............................................................................................................................................................................62
26 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5
Section 5(a). Medical Services and Supplies
Provided by Physicians and Other Health Care Professionals
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•We have no calendar year deductible.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Description You pay
Diagnostic and treatment services High Option Standard Option
Professional services of physicians
• During a hospital stay
• In a skilled nursing facility
• Vaccines for pediatric and adult immunizations
• Inpatient non-dental treatment of temporomandibular joint (TMJ)
syndrome
Nothing Nothing
• Office visits, including routine newborn circumcision performed
within 31 days of birth unrelated to illness or injury and asthma self-
management training.
• Office medical consultations
• Second opinions
$20 per visit $20 per visit
• Home visit by physician $25 per visit $25 per visit
• Self-referral to a Plan specialist under Access+ HMO and TRIO HMO
option
$30 per visit $30 per visit
• In an urgent care center $20 per visit $20 per visit
• Home visit by nurse or health aide $5 per visit $5 per visit
Teladoc High Option Standard Option
Teladoc provides access to a national network of board-certified doctors
and pediatricians in the U.S. who are available on-demand 24hr a day, 7
days a week, 365 days a year to diagnose, treat, and prescribe
medication (when necessary) for many medical issues via phone or
online video consultations.
Teladoc does not replace your existing primary care physician
relationships, but supplements them as a convenient, affordable,
alternative for medical care.
All covered employees, dependent spouses and dependent children are
eligible.
$20 per consult $20 per consult
27 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Lab, X-ray and other diagnostic tests High Option Standard Option
Tests, such as:
• Blood tests
• Urinalysis
• Pathology
• X-rays
• Ultrasound
• Electrocardiogram and EEG
• Genetic testing & diagnostic procedures for certain conditions
Nothing Nothing
Tests, such as:
• CT Scans
• PET Scans
• MRI
• Nuclear Scans
• Angiograms (including heart catheterizations)
• Arthrograms
• Myelograms
• Ultrasounds not associated with maternity care
$200 per test $200 per test
Preventive care, adult High Option Standard Option
Routine physical every year which includes:
Screenings, such as:
• Total Blood Cholesterol
• Depression
• Diabetes
• High Blood Pressure
• HIV
• Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy screening - every five years starting at age 50
-Colonoscopy screening - every ten years starting at age 50
Individual counseling on prevention and reducing health risks
Nothing Nothing
Well woman care: based on current recommendations such as:
• Cervical cancer screening (Pap smear)
• Human Papillomavirus (HPV) testing
• Chlamydia/Gonorrhea screening
• Osteoporosis screening
• Breast cancer screening
• Annual counseling for sexually transmitted infections.
Nothing Nothing
Preventive care, adult - continued on next page
28 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Preventive care, adult (cont.) High Option Standard Option
• Annual counseling and screening for human immune-deficiency virus.
• Contraceptive methods and counseling.
• Screening and counseling for interpersonal and domestic violence.
Note: Women's preventative services: https://www.healthcare.gov/
preventive-care-women/
Nothing Nothing
Routine mammogram - covered for women Nothing Nothing
Routine Prostate Specific Antigen (PSA) test – one annually for men age
40 and older
Nothing Nothing
Adult immunizations endorsed by the Centers for Disease Control and
Prevention (CDC): based on the Advisory Committee on Immunization
Practices (ACIP) schedule.
Nothing Nothing
Note: Any procedure, injection, diagnostic service, laboratory, or x-ray
service done in conjunction with a routine examination and is not
included in the preventive listing of services will be subject to the
applicable member copayments, coinsurance, and deductible.
Note: A complete list of preventive care services recommended under
the U.S. Preventive Services Task Force is available (USPSTF) is
available online at: www.uspreventiveservicestaskforce.org/Page/Name/
uspstf-a-and-b-recommendations/
HHS: www.healthcare.gov/preventive-care-benefits/
CDC: www.cdc.gov/vaccines/schedules/index.html
Women’s preventive services:
www.healthcare.gov/preventive-care-women/
For additional information: healthfinder.gov/myhealthfinder/default.aspx
Biometric screenings
Biometric screenings gather key health indicators such as total
cholesterol, blood pressure, BMI, Triglycerides, and fasting glucose.
Your PCP will record your values on the physician fax biometric
screening form and submit the form via fax that includes both you and
your doctor's signature. The form for the screening can be downloaded
at www.blueshieldca.com/federal
Walkadoo
™
is an easy-to-use walking program. As part of the program,
you will download either the Walkadoo or Moves app to your smart
phone or use your own personal FItbit to count your steps and then
connect your device to Walkadoo. Each morning, based on your
previous activity, you receive a step goal via e-mail or SMS.
On the Walkadoo website, you track your progress and connect with
others. If you like a little friendly rivalry, you can compete in Walkadoo
Derbies. With Walkadoo, you'll find yourself walking more in no time!
Nothing Nothing
Not covered: All charges All charges
Preventive care, adult - continued on next page
29 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Preventive care, adult (cont.) High Option Standard Option
•
Physical exams required for obtaining or continuing employment or
insurance, attending schools or camp, athletic exams, or travel.
•
Immunizations, boosters, and medications for travel or work-related
exposure..
All charges All charges
Preventive care, children High Option Standard Option
Well-child visits, examinations, and immunizations as described in the
Bright Future Guidelines provided by the American Academy of
Pediatrics
Nothing Nothing
Well-child care charges for routine examinations, immunizations and
care (through age 22)
Examinations such as:
• Eye exams through age 17 to determine the need for vision correction,
which include:
• Hearing exams through age 17 to determine the need for hearing
correction, which include:
• Examinations done on the day of immunizations (up to age 22)
Note: Any procedure, injection, diagnostic service, laboratory, or x-ray
service done in conjunction with a routine examination and is not
included in the preventive listing of services will be subject to the
applicable member copayments, coinsurance, and deductible.
Note: A complete list of preventive care services recommended under
the U.S. Preventive Services Task Force (USPSTF) is available online at
www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-
recommendations/
HHS: www.healthcare.gov/preventive-care-benefits/ .
CDC: www.cdc.gov/vaccines/schedules/index.html
For additional information: www.healthfinder.gov/myhealthfinder/
default.aspx
Note: For a complete list of the American Academy of Pediatrics Bright
Futures Guidelines go to www.brightfutures.aap.org/Pages/default.aspx
Nothing Nothing
Maternity care High Option Standard Option
Complete maternity (obstetrical) care, such as:
• Prenatal care
• Screening for gestational diabetes for pregnant women
• Delivery
• Postnatal care
Nothing Nothing
Breastfeeding support, supplies and counseling for each birth
• Comprehensive lactation support and counseling, by a trained
provider during pregnancy and/or in the postpartum period, and costs
for renting breastfeeding equipment.
Nothing Nothing
Maternity care - continued on next page
30 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Maternity care (cont.) High Option Standard Option
• Breast pump rental or purchase is only covered if obtained from a
designated Plan provider in accordance with Blue Shield Medical
Policy. For further information call Member Services at (800)
880-8086 or go to www.blueshieldca.com
Nothing Nothing
Note: Here are some things to keep in mind:
• You do not need to pre-certify your vaginal delivery; see page 30 for
other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery
and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.
• We cover routine nursery care of the newborn child during the
covered portion of the mother’s maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover
the infant under a Self Plus One or Self and Family enrollment.
Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity
care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and surgical benefits
Section(b).
Note: When a newborn requires definitive treatment during or after the
mother’s confinement, the newborn is considered a patient in his or her
own right. If the newborn is eligible for coverage, regular medical or
surgical benefits apply rather than maternity benefits.
Family planning High Option Standard Option
Contraceptive counseling on an annual basis Nothing Nothing
A range of voluntary family planning services, limited to:
• Voluntary sterilization counseling
• Tubal ligation
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo provera)
• Intrauterine devices (IUDs)
• Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.
Nothing Nothing
Voluntary sterilization (See Surgical procedures Section 5(b))
• Vasectomy $75 $75
Not covered:
•
Reversal of voluntary surgical sterilization
•
Genetic testing and counseling
All charges All charges
31 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Infertility services High Option Standard Option
Diagnosis and treatment of infertility such as:
• Artificial insemination (up to six cycles per pregnancy):
- Intravaginal insemination (IVI)
- Intra-cervical insemination (ICI)
- Intrauterine insemination (IUI)
Covered injectable fertility drugs
Note: We cover Injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.
50% of plan
allowance
50% of plan
allowance
Oral fertility drugs (See
Prescription Drug Benefits
) Regular cost sharing Regular cost sharing
Not covered:
•
Infertility services after voluntary sterilization
•
Assisted reproductive technology (ART) procedures, such as:
-
Artificial insemination (AI)
-
in vitro fertilization (IVF)
-
embryo transfer, gamete intrafallopian transfer (GIFT) and zygote
intrafallopian transfer (ZIFT)
•
Services, supplies and drugs related to excluded ART procedures
•
Cost of donor sperm, eggs and frozen embryos and their collection
and storage
All charges All charges
Allergy care High Option Standard Option
• Allergy serum Nothing Nothing
• Testing and treatment
• Allergy injection
$20 per visit $20 per visit
• Customized antigens 50% of plan
allowance
50% of plan
allowance
Not covered:
•
Provocative food testing
and
sublingual allergy desensitization
All charges All charges
Treatment therapies High Option Standard Option
• Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under Organ/
Tissue Transplants on page 40.
• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is
provided at a Plan facility, if medically necessary with the appropriate
treatment plan.
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
$20 per visit $20 per visit
Treatment therapies - continued on next page
32 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Treatment therapies (cont.) High Option Standard Option
Note: Growth hormone is covered under the prescription drug benefit.
Note: We only cover GHT when we preauthorize the treatment. We will
ask you to submit information that establishes that the GHT is medically
necessary. Ask us to authorize GHT before you begin treatment. We
will only cover GHT services and related services and supplies that we
determine are medically necessary. See
Other services under You need
prior Plan approval for certain services
on page 19.
$20 per visit $20 per visit
Physical and occupational therapies High Option Standard Option
These are covered benefits when determined by us to be medically
necessary and it is demonstrated that the member’s condition will
significantly improve as a result of the rehabilitative and/or habilitative
services.
• Qualified physical therapists
• Occupational therapists.
Note: Occupational therapy is limited to services that assist the member
to achieve and maintain self-care and improved functioning in other
activities of daily living.
$20 per visit $20 per visit
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided at a Plan facility, if medically
necessary with the appropriate treatment plan.
$20 per visit $20 per visit
Not covered:
•
Long-term rehabilitative therapy
•
Exercise programs
All charges All charges
Speech therapy High Option Standard Option
Speech therapy by a qualified speech therapist is covered when it is
determined by us to be medically necessary and it is demonstrated that
the member’s condition will significantly improve as a result of the
rehabilitative and/or habilitative services.
$20 per visit $20 per visit
Hearing services (testing, treatment, and supplies) High Option Standard Option
• For treatment related to illness or injury, including evaluation and
diagnostic hearing tests performed by an M.D., D.O., or audiologist
Note: For routine hearing screening performed during a child’s
preventive care visit, see Section 5(a)
Preventive care, children
.
$20 per visit $20 per visit
Audiological evaluation to measure hearing loss and to determine the
most appropriate make and model of hearing aid.
$20 per visit $20 per visit
Not covered:
•
All other hearing testing
•
Batteries and other equipment after the initial purchase of your
hearing aid.
•
Charges for a hearing aid that exceeds the requirements prescribed for
the correction of your hearing loss.
•
Replacement parts and repair after one year
All charges All charges
Hearing services (testing, treatment, and supplies) - continued on next page
33 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Hearing services (testing, treatment, and supplies) (cont.) High Option Standard Option
•
Replacement of hearing aid more than once in any period of 24
months.
All charges All charges
Vision services (testing, treatment, and supplies) High Option Standard Option
Contact lenses, if medically necessary to treat eye conditions such as
keratoconus, keratitis sicca and aphakia or when required as a result of
cataract surgery when no intraocular lens has been implanted, are
covered.
$20 per visit $20 per visit
Annual eye refraction; in addition to the medical and surgical benefits
provided for diagnosis and treatment of disease of the eye, an annual eye
refraction (to provide a written lens prescription) may be obtained from
Vision Plan Administration (VPA) providers. VPA provider directories
can be accessed through www.blueshieldca.com/federal or by calling
Blue Shield Member Service at (800) 880-8086.
Note: See
Preventive care, children
for eye screenings for children.
$20 per visit $20 per visit
Not covered:
•
Eyeglasses or contact lenses (See page 67 for details about eyewear
discounts)
•
Eye exercises and orthoptics
•
Radial keratotomy, refractive keratoplasty and other refractive
surgery
•
Video assisted visual aids or video magnification equipment
All charges All charges
Foot care High Option Standard Option
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes.
Note: See Orthopedic and prosthetic devices for information on
podiatric shoe inserts.
$20 per visit $20 per visit
Not covered: Routine foot care All charges All charges
Orthopedic and prosthetic devices High Option Standard Option
• Surgically implanted breast implant following mastectomy
• Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
• Blom-Singer and artificial larynx prostheses following a
laryngectomy
• Prosthetic sleeve or sock
Nothing Nothing
• Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy.
- Inpatient Hospital
- Outpatient Hospital
Nothing for the device Nothing for the device
Orthopedic and prosthetic devices - continued on next page
34 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Orthopedic and prosthetic devices (cont.) High Option Standard Option
Note: For information on the professional charges for the surgery to
insert an implant, see Section 5(b) Surgical procedures. For information
on the hospital and/or ambulatory surgery center benefits, see Section 5
(c) Services provided by a hospital or other facility, and ambulance
services.
• Orthopedic devices (and their repair) such as braces; or foot orthoses
that are custom-made and demonstrated to have therapeutic effect.
• Prosthetic devices (and their repair) such as artificial limbs and
contact lenses necessary to treat certain medical eye conditions.
Contact us for details.
50% of plan
allowance
50% of plan
allowance
• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing
aids (BAHA) and cochlear implants
• Includes supplies such as the initial battery, cords and other hearing
aid equipment. Includes visits for fitting, counseling, adjustments, and
repairs for one year after you receive your hearing aid(s). We will pay
up to a maximum of $1,000 per member every 24 months for both
ears for the hearing aid instrument, supplies and equipment.
Charges above the
maximum payment of
$1,000 per member
every 24 months
Charges above the
maximum payment of
$1,000 per member
every 24 months
Not covered:
•
Orthopedic and corrective shoes, arch supports, foot orthotics, heel
pads, and heel cups
•
Lumbosacral supports
•
Corsets, trusses, elastic stockings, support hose, and other supportive
devices
•
Penile prostheses
•
Backup or alternate items
All charges All charges
Durable medical equipment (DME) High Option Standard Option
Purchase or rental up to the purchase price, including repair and
adjustment, of durable medical equipment prescribed by your Plan
physician. Replacement of DME is covered only when it no longer
meets the clinical needs of the patient or has exceeded the expected
lifetime of the item. Under this benefit, we cover:
• Oxygen
• Dialysis equipment
• Colostomy/ostomy supplies
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Canes
• Traction equipment
• Blood glucose monitors
• Apnea monitor for management of newborns
50% of plan
allowance with no
annual maximum
50% of plan
allowance with no
annual maximum
Durable medical equipment (DME) - continued on next page
35 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Durable medical equipment (DME) (cont.) High Option Standard Option
• Nebulizers, including face masks and tubing, and peak flow monitors
for the management and treatment of asthma. See section 5(f)
Prescription Drug Benefits for asthma inhalers and inhaler spacers.
Note: Call us at (800) 880-8086 as soon as your Plan physician
prescribes this equipment. We have contracted with health care providers
to rent or sell you durable medical equipment at discounted rates and we
will tell you more about this service when you call.
50% of plan
allowance with no
annual maximum
50% of plan
allowance with no
annual maximum
Not covered:
•
Exercise equipment
•
Disposable medical supplies for home use, except colostomy/ostomy
supplies
•
Speech/language assistance devices except as listed under prosthetic
devices
•
Self-monitoring equipment and home testing devices, except as listed
in the covered section
•
Wigs
•
Generators
•
Backup or alternate items
All charges All charges
Home health services High Option Standard Option
• Home health care ordered by a Plan physician and provided by a
registered nurse (R.N.), Physical Therapist (PT), Occupational
Therapist (OT), Speech Therapist (ST), Respiratory Therapist (RT),
licensed vocational nurse (L.V.N.), or home health aide
• Services include oxygen therapy, intravenous therapy and
medications, except for home self-administered injectable drugs
Note: See Section 5(f) Prescription Drug Benefits for home self-
injectable therapy obtained from a Plan pharmacy.
$5 per visit $5 per visit
• Home visit by physician $25 per visit $25 per visit
Not covered:
•
Nursing care requested by, or for the convenience of, the patient or the
patient’s family
•
Services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication
•
Drugs or supplies that do not require a physician's prescription, even
if a physician prescribes them, unless they are listed as covered
All charges All charges
36 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Chiropractic/Alternative treatments High Option Standard Option
Chiropractic services (up to 20 medically necessary visits per year);
members may self-refer to American Specialty Health Plans of
California, Inc. (ASH Plans) Providers by calling 800-678-9133 or
visiting our website for participating practitioners
$10 per visit $10 per visit
Each member is allowed a pre-authorized appliance benefit of up to $50
per year.
Appliance benefits that are pre-authorized such as:
• Elbow supports
• Back supports (Thoracic)
• Cervical collars
All charges above $50
per year
All charges above $50
per year
Not covered:
•
All charges after the 20 visit annual maximum
•
Naturopathic services
•
Hypnotherapy
•
Services for or related to acupuncture
Note: See page 67 for Non-FEHB benefits available to plan members.
Discount programs are available through the mylifepath Alternative
Health Services Discount Program for acupuncture, chiropractic and
massage therapy.
All charges All charges
Educational classes and programs High Option Standard Option
Coverage is provided for:
• Preventive health reminders and educational publications available
online at www.blueshieldca.com/federal
Nothing Nothing
Health Risk Assessment and online wellness tools
The Health Risk Assessment is an online tool that helps members
discover potential health risks and recommends positive steps to control
those risks. There are multiple wellness online tools and content
available for members to learn more about becoming healthy and assist
with making small behavior changes and help members create healthy
changes.
You can access the Health Risk Assessment by logging into your
account at www.blueshieldca.com.
Quit Net: This industry-leading program provided by Healthways uses a
proven approach to behavior change that recognizes stages of change,
supports the decision-making process, builds self-confidence, and
incorporates motivational interviewing techniques. QuitNet Digital Plus
integrates digital tools delivered through an open social platform with
telephonic coaching and nicotine replacement therapy to drive ongoing
engagement and increase the chances of tobacco cessation. QuitNet
Digital Plus program interventions include:
• A lifetime digital membership to online interventions that use a
combination of assessments, social dynamics, and game mechanics to
engage and support participant objectives
Nothing Nothing
Educational classes and programs - continued on next page
37 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Educational classes and programs (cont.) High Option Standard Option
• 24/7 access to the QuitNet community, a therapeutic online community
with thousands of interactions per day (e.g., pledging, encouraging,
smiling, commenting) that provide participants with real-time responses
to posts
• The ability to engage with certified tobacco cessation counselors
within the social community and via private messaging
• A printed QuitGuide, an evidence-based, comprehensive guide to
quitting smoking with best practices as recommended by the U.S. Public
Health Service and the experience of millions of ex-smokers
• Daily quit tips delivered by email and/or SMS
• Mobile access through iOS app and mobile browsers
• Mail order fulfillment of over-the-counter nicotine replacement therapy
• Telephonic coaching with unlimited inbound support via a dedicated
toll-free number
To enroll in Quit Net Digital Plus visit mywellvolution.com and enroll.
Once at the programs page, click on the Quit Net icon.
Note: No copay for generic, brand name and over-the-counter tobacco
cessation medications when prescribed by a physician. If you request a
brand name prescription medication over an available generic version,
then you will be responsible for the generic copayment plus the
difference in price of brand name and generic drugs.
See also: Section 5(f) - Prescription drug benefits, page 53.
Nothing Nothing
Prenatal Program – offering a wide range of educational materials to
support health during pregnancy (preparation and staying healthy) and
post-delivery (postpartum care, caring for an infant and toddler),
including:
•
Prenatal Guide
filled with information on fitness, nutrition, emotions,
body changes, doctor visits, prenatal tests, postpartum depression, and
a home safety checklist to prepare for the baby’s arrival
• Text4Baby
sm
enrollment information
• Personal pregnancy calendar
• First-aid chart
• Vaccination information
• Information about postnatal care
For more information, or to enroll, visit www.blueshieldca.com/hw
Nothing Nothing
Programs for members 65 and older
Preventive care visits to discuss exercise or physical therapy and vitamin
D supplementation to prevent falls is a covered service for patients who
meet all of the following criteria (OTC medications are not a covered
benefit):community-dwelling adults (excluding institutionalized,
facility-based adults, such as those in Skilled Nursing Facilities) aged 65
years or older at increased risk for fall.
Nothing Nothing
Educational classes and programs - continued on next page
38 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Educational classes and programs (cont.) High Option Standard Option
Behavioral counseling to prevent skin cancer for children and young
adults age 10 - 24
Behavioral counseling about minimizing exposure to ultraviolet
radiation to reduce risk for skin cancer is a covered service for patients
with fair skin who meet any of the following criteria: Children age 10
and older to young adults to age 24. These services are considered
inclusive in the preventive care visit, and therefore not separately
reimbursable
Nothing Nothing
Clinical trials High Option Standard Option
Benefits are provided for routine patient care for a member whose
personal physician has obtained prior authorization from the Plan and
who has been accepted into an approved clinical trial provided that:
1. The clinical trial has a therapeutic intent and the member’s treating
physician determines that participation in the clinical trial has a
meaningful potential to benefit the member with a therapeutic intent;
and
2. The member’s treating physician recommends participation in the
clinical trial; and
3. The hospital and/or physician conducting the clinical trial is a Plan
provider, unless the protocol for the trial is not available through a
Plan provider.
Charges for routine patient care will be paid on the same basis and at the
same benefit levels as any other similar covered service or supply.
Routine patient care consists of those services that would otherwise be
covered by the Plan if those services were not provided in connection
with an approved clinical trial, but does not include:
1. Drugs or devices that have not been approved by the federal Food and
Drug Administration (FDA);
2. Services other than health care services, such as travel, housing,
companion expenses and other non-clinical expenses;
3. Any item or service that is provided solely to satisfy data collection
and analysis needs and that is not used in the clinical management of
the patient;
4. Services that, except for the fact that they are being provided in a
clinical trial, are specifically excluded under the Plan;
5. Services customarily provided by the research sponsor free of charge
for any enrollee in the trial.
An approved clinical trial is limited to a trial that is:
1. Approved by one of the following:
• one of the National Institutes of Health;
• the US Food and Drug Administration, in the form of an
investigational new drug application;
• the United States Department of Defense;
• the United States Veteran's Administration; or
Please see Section 9
for additional
information for costs
related to clinical
trials
Please see Section 9
for additional
information for costs
related to clinical
trials
Clinical trials - continued on next page
39 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
High and Standard Option
Benefit Description You pay
Clinical trials (cont.) High Option Standard Option
• involves a drug that is exempt under federal regulations from a new
drug application.
Please see Section 9
for additional
information for costs
related to clinical
trials
Please see Section 9
for additional
information for costs
related to clinical
trials
40 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(a)
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other
Health Care Professionals
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•We have no calendar year deductible.
•Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The services listed below are for the charges billed by a physician or other health care professional
for your surgical care. See Section 5(c) for charges associated with the facility charge (i.e. hospital,
surgical center, etc.).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require precertification.
Benefit Description You pay
Surgical procedures High Option Standard
Option
A comprehensive range of services, such as:
• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus, when medically necessary
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see reconstructive surgery)
• Treatment of burns
• Circumcisions performed during newborn’s post delivery stay in hospital
• Surgical treatment of morbid obesity (bariatric surgery) – for members who meet
Blue Shield Medical Policy and clinical criteria for covered procedures and services
that have been approved by their primary care physicians.
Covered procedures:
• Roux-en-Y Gastric Bypass
• Vertical Banded Gastroplasty
• Duodenal Switch, Distal Gastric Bypass limited to Body Mass Index (BMI) of 50 or
greater
• Laparoscopic Adjustable Gastric Band
Clinical criteria includes, but is not limited to:
$20 per office
visit when
service
provided in the
office
For inpatient
hospital co-
pay, please see
section 5(c).
$20 per office
visit when
service
provided in the
office
For inpatient
hospital co-
pay, please see
section 5(c).
Surgical procedures - continued on next page
41 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
High and Standard Option
Benefit Description You pay
Surgical procedures (cont.) High Option Standard
Option
• The patient has a BMI greater than 40 or between 35 and 40 with a co-morbid
condition such as a life-threatening cardiopulmonary condition, severe or
uncontrolled diabetes, or sleep apnea.
• It is the first surgery for obesity.
• There is documentation showing a comprehensive history and physical evaluation,
done within the last three months
• The patient has actively participated in physician-directed non-surgical methods of
weight reduction
• There is documentation for a recent psychological evaluation
For more information regarding clinical criteria for covered procedures, please contact
us at (800) 880-8086 and we will assist you.
$20 per office
visit when
service
provided in the
office
For inpatient
hospital co-
pay, please see
section 5(c).
$20 per office
visit when
service
provided in the
office
For inpatient
hospital co-
pay, please see
section 5(c).
Insertion of internal prosthetic devices. See Section 5(a) Orthopedic and prosthetic
devices for device coverage information.
$10 per
procedure
$10 per
procedure
Outpatient hospital surgery and supplies including routine newborn circumcision
performed within 31 days of birth unrelated to illness or injury
$250 per
surgery
$250 per
surgery
Voluntary Sterilization
• Vasectomy $75 $75
• Tubal ligation Nothing Nothing
Not covered:
•
Surgical treatment of morbid obesity (bariatric surgery) procedures not listed as
covered and repeat surgery due to behavioral failure
•
Reversal of voluntary sterilization
•
Routine treatment of conditions of the foot; (see Foot care)
All Charges All Charges
Reconstructive surgery High Option Standard
Option
• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
- the condition produced a major effect on the member’s appearance and
- the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant
deviation from the common form or norm. Examples of congenital anomalies are:
protruding ear deformities, cleft lip, cleft palate, birth marks, webbed fingers, and
webbed toes
• Surgery to correct cleft lip and cleft palate include dental or orthodontic services that
are an integral part of the reconstructive surgery.
• Gender reassignment surgery for the treatment of gender dysphoria. Requires prior
authorization. (see page 20, Section 3)
Outpatient
hospital copay
applies - $250
per treatment
or surgery
For inpatient
hospital co-
pay, please see
section 5(c).
Outpatient
hospital copay
applies - $250
per treatment
or surgery
For inpatient
hospital co-
pay, please see
section 5(c).
• All stages of breast reconstruction surgery following a mastectomy, such as:
- Surgery to produce a symmetrical appearance of breasts;
- Treatment of any physical complications, such as lymphedemas;
- Breast prostheses and surgical bras and replacements (see
Prosthetic devices
)
Outpatient
hospital copay
applies - $250
per treatment
or surgery
Outpatient
hospital copay
applies - $250
per treatment
or surgery
Reconstructive surgery - continued on next page
42 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
High and Standard Option
Benefit Description You pay
Reconstructive surgery (cont.) High Option Standard
Option
Note: If you need a mastectomy, you may choose to have this procedure performed on
an inpatient basis and remain in the hospital up to 48 hours after the procedure.
Outpatient
hospital copay
applies - $250
per treatment
or surgery
For inpatient
hospital co-
pay, please see
section 5(c).
Outpatient
hospital copay
applies - $250
per treatment
or surgery
For inpatient
hospital co-
pay, please see
section 5(c).
Not Covered
•
Cosmetic Surgeries that are not Medically Necessary.
•
Reversal of gender reassignment surgery.
All Charges All Charges
Oral and maxillofacial surgery High Option Standard
Option
Oral surgical procedures, limited to:
• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Surgical and anthroscopic treatment of TMJ is covered if prior history shows
conservative medical treatment has failed. Splint therapy and physical therapy is
covered, see Section 5(a)
• Other surgical procedures that do not involve the teeth or their supporting structures
Outpatient
hospital copay
applies - $250
per treatment
or surgery
Inpatient
hospital copay
applies. Please
see section 5
(c).
Outpatient
hospital copay
applies - $250
per treatment
or surgery
Inpatient
hospital copay
applies. Please
see section 5
(c).
Not covered:
•
Oral implants and transplants
•
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva, and alveolar bone)
All charges All charges
Organ/tissue transplants High Option Standard
Option
These solid organ transplants are covered. Solid organ transplants are limited to:
• Autologous pancreas islet cell transplant (as an adjunct to total or near total
pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
- Isolated small intestine
- Small intestine with the liver
- Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
Nothing Nothing
Organ/tissue transplants - continued on next page
43 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard
Option
• Kidney-Pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas
These tandem blood or marrow stem cell transplants for covered transplants are
subject to medical necessity review by the Plan. Refer to
Other services
in Section 3
for prior authorization procedures.
• Autologous tandem transplants for
- AL Amyloidosis
- Multiple myeloma (de novo and treated)
- Recurrent germ cell tumors (including testicular cancer)
Nothing Nothing
Blood or marrow stem cell transplants. The Plan extends coverage for the diagnoses
as indicated below.
• Allogeneic transplants for
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Advanced Hodgkin’s lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
- Acute myeloid leukemia
- Advanced Myeloproliferative Disorders (MPDs)
- Advanced neuroblastoma
- Amyloidosis
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
- Hemoglobinopathy
- Infantile malignant osteopetrosis
- Kostmann's syndrome
- Leukocyte adhesion deficiencies
- Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal
Hemoglobinuria, Pure Red Cell Aplasia)
- Mucolipidosis (e.g. Gaucher's disease, metchromatic leukodystrophy,
adrenoleukodystrophy)
- Mucoplysaccharidosis (e.g. Hurler's syndrome, Maroteaux-Lamy syndrome
variants)
- Myelodysplasia/Myelodysplastic syndromes
- Paroxysmal Nocturnal Hemoglobinuria
- Phagocytic/Hemophagocytic deficiency diseases (e.g. Wiskott-Aldrich syndrome)
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
- Sickle cell anemia
- X-linked lymphoproliferative syndrome
• Autologous transplants for:
Nothing Nothing
Organ/tissue transplants - continued on next page
44 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard
Option
- Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
- Advanced Hodgkin’s lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
- Amyloidosis
- Ependymoblastoma
- Ewing's sarcoma
- Multiple myeloma
- Medullablastoma
- Pineoblastoma
- Neuroblastoma
- Testicular, mediastinal, Retroperitoneal, and ovarian germ cell tumors
Mini-transplants performed in a clinical trial setting (non-myeloblative, reduced
intensity conditioning or RIC) for members with a diagnosis listed below are subject to
a medical necessity review by the Plan.
Refer to
Services requiring our prior approval
in Section 3 for prior authorization
procedures.
• Allogenic transplants for
- Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia
- Advanced Hodgkin's lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
- Acute myeloid leukemia
- Advanced Myeloproliferative Disorders (MPDs)
- Amyloidosis
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
- Hemoglobinopathy
- Marrow failure and related disorders (i.e. Franconi's, PNH, Pure Red Cell Aplasia)
- Myelodyplasia/Myelodysplastic syndromes
- Paroxysmal Nocturnal Hemoglobinuria
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
• Autologous transplants for
- Acute lymphocytic or nonlymphocytic (i.e. myelogenous) leukemia
- Advanced Hodgkin's lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
- Amyloidosis
- Neuroblastoma
Nothing Nothing
Organ/tissue transplants - continued on next page
45 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard
Option
These blood or marrow stem cell transplants covered only in a National Cancer Institute
or National Institutes of Health approved clinical trial or a Plan-designated center of
excellence and if approved by the Plan's medical director in accordance with the Plan's
protocols.
If you are a participant in a clinical trial, the Plan will provide benefits for related
routine care that is medically necessary (such as doctor visits, lab tests, x-rays and
scans, and hospitalization related to treating the patient's condition) if it not provided by
the clinical trial. Section 9 has additional information on costs related to clinical trials.
We encourage you to contact the Plan to discuss specific services if you participate in a
clinical trial.
• Allogenic transplants for
- Advanced Hodgkin's lymphoma
- Advanced non-Hodgkin's lymphoma
- Beta Thalassemia Major
- Chronic inflamatory demyelination polyneuropathy (CIDP)
- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
- Multiple myeloma
- Multiple sclerosis
- Sickle cell anemia
• Mini-transplants (non-myeloblative allogenic, reduced intensity conditioning or RIC)
for
- Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia
- Advanced Hodgkin's lymphoma
- Advanced non-Hodgkin's lymphoma
- Breast cancer
- Chronic lymphocytic leukemia
- Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
- Chronic myelogenous leukemia
- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
- Multiple myeloma
- Myeloproliferative disorders (MPDs)
- Renal cell carcinoma
- Sickle cell anemia
• Autologous Transplants for
- Advanced Childhood Kidney cancers
- Advanced Ewing sarcoma
- Advanced Hodgkin's Lymphoma
- Advanced non-Hodgkin's lymphoma
- Aggressive non-Hodgkin's lymphoma
- Breast Cancer
- Childhood rhabdomyosarcoma
Please see
Section 9 for
additional
information
for costs
related to
clinical trials.
Please see
Section 9 for
additional
information
for costs
related to
clinical trials.
Organ/tissue transplants - continued on next page
46 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard
Option
- Chronic myelogenous leukemia
- Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
- Epithelial Ovarian Cancer
- Mantle Cell (Non-Hodgkin Lymphoma)
- Multiple sclerosis
Note: We cover related medical and hospital expenses of the donor when we cover the
recipient.
Please see
Section 9 for
additional
information
for costs
related to
clinical trials.
Please see
Section 9 for
additional
information
for costs
related to
clinical trials.
Not covered:
•
Donor screening tests and donor search expenses, except those performed for the
actual donor
•
Implants of artificial organs
•
Transplants not listed as covered
•
Travel expenses unless authorized by us
All Charges All Charges
Anesthesia High Option Standard
Option
Professional services provided in:
• Hospital (inpatient)
• Skilled Nursing Facility
Nothing Nothing
Professional services provided in:
• Hospital outpatient department
• Ambulatory surgical center
• Office
Outpatient
hospital copay
applies - $250
per treatment
or surgery
Outpatient
hospital copay
applies - $250
per treatment
or surgery
47 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(b)
Section 5(c). Services Provided by a Hospital or
Other Facility, and Ambulance Services
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
•We have no calendar year deductible.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center)
or ambulance service for your surgery or care. Any costs associated with the professional charge (i.
e., physicians, etc.) are covered in Sections 5(a) or (b).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.
Benefit Description You pay
Inpatient hospital High Option Standard
Option
Room and board, such as:
• Semiprivate or intensive care accommodations
• General nursing care
• Meals and special diets when medically necessary
• Special duty nursing when medically necessary
• Private rooms when medically necessary
NOTE: If you want a private room when it is not medically necessary, you pay the
additional charge above the semiprivate room rate.
$200 per day
up to 3 days
$200 per day
up to 3 days
Other hospital services and supplies, such as:
• Operating, recovery, delivery room, newborn nursery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and x-rays
• Administration of blood and blood products
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a
hospital for use at home
• Radiation therapy, chemotherapy, and renal dialysis
Nothing Nothing
Not covered:
•
Custodial care
All Charges All Charges
Inpatient hospital - continued on next page
48 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(c)
High and Standard Option
Benefit Description You pay
Inpatient hospital (cont.) High Option Standard
Option
•
Non-covered facilities, such as nursing homes, convalescent care facilities and
schools
•
Personal comfort items, such as telephone, television, barber services, guest meals
and beds
•
Private nursing care
All Charges All Charges
Outpatient hospital or ambulatory surgical center High Option Standard
Option
• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, x-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental procedures when
necessitated by a non-dental physical impairment. We do not cover dental procedures
for non-accidental injury to natural teeth. See page 61.
$250 per
treatment or
surgery
including
necessary
supplies
$250 per
treatment or
surgery
including
necessary
supplies
Not covered: Blood and blood derivatives not replaced by the member All charges All charges
Extended care benefits/Skilled nursing care facility benefits High Option Standard
Option
We provide benefits up to 100 days each calendar year when full time skilled nursing
care is necessary and confinement in a skilled nursing facility is medically appropriate
as determined by your Plan physician and approved by us. Admissions to a sub-acute
care setting require prior approval and are limited to 100 days each calendar year. All
necessary services are covered, including:
• Bed, board and general nursing care
• Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan physician
Nothing Nothing
Not covered: Custodial care, rest cures, domiciliary or convalescent care and comfort
items such as a telephone and television. All charges after the 100 day annual
maximum.
All Charges All Charges
Hospice care High Option Standard
Option
We cover the following services through a participating hospice agency when the
member has a terminal illness with a prognosis of life of one year or less as determined
by the member's Plan provider’s certification. Admission to the hospice program must
be prior approved by Blue Shield and the delegated IPA/MG. If the member lives
longer than one year, hospice coverage can continue for a period of care if the Plan
provider recertifies that the member still needs and remains eligible for hospice care.
Upon recertification a member can receive care for two 90-day periods followed by an
unlimited number of 60-day periods.
Nothing in a
hospice
facility
Nothing for
home
physician visit
Nothing in a
hospice
facility
Nothing for
home
physician visit
Hospice care - continued on next page
49 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(c)
High and Standard Option
Benefit Description You pay
Hospice care (cont.) High Option Standard
Option
Members can continue to receive covered services that are not related to the palliation
and management of the terminal illness from the appropriate Plan provider. Subject to
appropriate Plan copays for the type of covered services.
Hospice coverage includes:
• Pre-hospice consultative visit regarding pain and symptom management, hospice and
other care options including care planning (You do not have to be enrolled in the
hospice program to receive this benefit).
• Interdisciplinary team care to develop and maintain an appropriate plan of care.
• Nursing care services are covered on a continuous basis for as much as 24 hours a
day during periods of crisis as necessary to maintain a member at home.
Hospitalization is covered when the interdisciplinary team makes the determination
that skilled nursing care is required at a level that can’t be provided in the home.
• Skilled nursing services, certified health aide services and homemaker services under
the supervision of a qualified registered nurse.
• Drugs and medicine, medical equipment and supplies that are reasonable and
necessary for the palliation and management of terminal illness and related
conditions.
• Physical therapy, occupational therapy, and speech-language pathology services for
purposes of symptom control, or to enable the enrollee to maintain activities of daily
living and basic functional skills.
• Social services/counseling services with medical social services provided by a
qualified social worker. Dietary counseling, by a qualified provider, will also be
provided when needed.
• Short-term inpatient care necessary to relieve family members or other persons
caring for the member. Such respite care is limited to an occasional basis and to no
more than five consecutive days at a time.
• Volunteer services.
• Bereavement services.
Nothing in a
hospice
facility
Nothing for
home
physician visit
Nothing for
visit of other
health care
providers
Nothing in a
hospice
facility
Nothing for
home
physician visit
Nothing for
visit of other
health care
providers
Not covered: Independent nursing, homemaker services All Charges All Charges
Ambulance High Option Standard
Option
Local professional ambulance service when ordered or authorized by a Plan physician. Nothing Nothing
50 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(c)
Section 5(d). Emergency Services/Accidents
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•We have no calendar year deductible.
•Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•No prior authorization is required.
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care, including active labor, and a
psychiatric medical condition. Some problems are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area
If you are in an emergency situation, please call your local emergency system (e.g., the 911 telephone system), where
available, or go to the nearest hospital emergency room. Please call your primary care physician as soon as it is reasonably
possible. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us. You or a family
member should notify us. It is your responsibility to ensure that we have been notified.
If you need to be hospitalized, we must be notified immediately following your admission, unless it was not reasonably
possible to notify us within that time. If you are hospitalized in a non-Plan facility and a Plan physician believes care can be
better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in
full.
Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant jeopardy to your condition. Any follow-up care recommended by non-Plan
providers must be approved by us or provided by Plan providers.
We pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan
providers. If the emergency results in admission to a hospital, any applicable copayment is waived.
Emergencies outside our service area
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen
illness.
If you need to be hospitalized, we must be notified immediately following your admissions, unless it was not reasonably
possible to notify us within that time. If you are hospitalized in a non-Plan facility and a Plan physician believes care can be
better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in
full.
Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan
providers.
Note: If the emergency results in admission to a hospital, the copayment is waived.
51 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(d)
High and Standard Option
Benefit Description You pay
Emergency within our service area High Option Standard
Option
Emergency care at a doctor's office $20 per visit $20 per visit
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors' services
Note: If the emergency results in admission to a hospital, the copayment is waived.
$20 per visit
$100 per visit
$20 per visit
$100 per visit
Not covered: Elective care or non-emergency care All Charges All Charges
Emergency outside our service area High Option Standard
Option
Emergency care at a doctor's office $20 per visit $20 per visit
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services
Note: If the emergency results in admission to a hospital, the copayment is waived.
$20 per visit
$100 per visit
$20 per visit
$100 per visit
Not covered: Elective care or non-emergency care All Charges All Charges
Ambulance High Option Standard
Option
Professional ambulance service when medically appropriate. Note: See Section 5(c) for
non-emergency service.
Nothing Nothing
Not covered: Taxi, wheelchair van, other non-ambulance assisted transportation All Charges All Charges
52 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(d)
Section 5(e). Mental Health and Substance Use Disorder Benefits
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•We have no calendar year deductible.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including
Medicare.
•We will provide medical review criteria or reasons for treatment plan denials to enrollees, members
or providers upon request or as otherwise required.
•OPM will base its review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.
Benefit Description You pay
Routine outpatient mental health and substance misuse disorder
benefits
High Option Standard
Option
All diagnostic and treatment services recommended by Plan providers and contained in
a treatment plan that we approve. The treatment plan may include services, drugs, and
supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive the care as part of a
treatment plan that we approve.
Your cost-
sharing
responsibilities
are no greater
than for other
illnesses or
conditions.
Your cost-
sharing
responsibilities
are no greater
than for other
illnesses or
conditions.
Benefits are provided for professional (Physician) office visits for the diagnosis and
treatment of Mental Health and Substance Misuse Disorder Conditions in the
individual, family or group setting.
$20 per visit $20 per visit
Non-routine outpatient mental health and substance misuse disorder
benefits
High Option Standard
Option
Benefits are provided for outpatient facility and professional services for the diagnosis
and treatment of Mental Health and Substance Misuse Disorder Conditions. These
services may also be provided in the office, home or other non-institutional setting.
Non-routine outpatient mental health and substance misuse disorder services must be
prior authorized by the MHSA.
Non-routine outpatient mental health and substance misuse disorder services include,
but may not be limited to, the following:
Intensive Outpatient Program (IOP) - an outpatient mental health or
substance misuse disorder treatment program utilized when a patient’s condition
requires structure, monitoring, and medical/psychological intervention at least three
hours per day, three days per week.
Nothing Nothing
Office-based opioid treatment – outpatient opioid detoxification and/or maintenance
therapy.
Nothing Nothing
Psychological Testing - testing to diagnose a Mental Health Condition when referred
by an MHSMD Participating Provider.
Nothing Nothing
Transcranial Magnetic Stimulation - a non-invasive method of delivering electrical
stimulation to the brain for the treatment of severe depression.
Nothing Nothing
Non-routine outpatient mental health and substance misuse disorder benefits - continued on next page
53 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(e)
High and Standard Option
Benefit Description You pay
Non-routine outpatient mental health and substance misuse disorder
benefits (cont.)
High Option Standard
Option
Electroconvulsive Therapy (ECT) – the passing of a small electric current through the
brain to induce a seizure, used in the treatment of severe mental health conditions.
Nothing Nothing
Partial Hospitalization Program (PHP) (also referred to as day care) – an
outpatient treatment program that may be freestanding or Hospital-based and provides
services at least five hours per day, four days per week. Members may be admitted
directly to this level of care, or transferred from inpatient care following acute
stabilization.
*An episode of care is the date from which you are admitted to the partial
hospitalization program in a facility to the date you are discharged or voluntarily leave
treatment. Any services received between these two dates constitute an episode of care.
If you need to be readmitted at a later date, this would constitute another episode of
care.
Nothing Nothing
Applied Behavior Analysis (ABA) Therapy / Behavioral Health Treatment
(BHT) – Professional services and treatment programs, including applied behavior
analysis and evidence-based intervention programs that develop or restore, to the
maximum extent practicable, the functioning of an individual with pervasive
developmental disorder or autism.
ABA/BHT is covered when prescribed by a Physician or licensed psychologist who is a
Plan Provider and the treatment is provided under a treatment plan prescribed by an
MHSMD Participating Provider. ABA/BHT must be prior authorized by the MHSA and
obtained from MHSMD Participating Providers. ABA/BHT used for the purposes of
providing respite, day care, or educational services, or to reimburse a parent for
participation in the treatment is not covered.
Nothing Nothing
Inpatient services High Option Standard
Option
Benefits are provided for inpatient hospital and professional services in connection with
acute hospitalization and residential care admission for treatment of Mental Health
Conditions or Misuse Disorder Conditions.
Inpatient services for the treatment of mental health and substance misuse must be prior
authorized by the MHSA.
$200 per day
up to 3 days
$200 per day
up to 3 days
Prior authorization is required for all non-emergency mental health and substance misuse
hospital admissions including acute inpatient care and residental care.
Non-routine outpatient mental health services, including, but not limited to, Behavioral
Health Treatment, Partial Hospitalization Program (PHP), Intensive Outpatient Program
(IOP), Electroconvulsive Therapy (ECT), Psychological Testing and Transcranial
Magnetic Stimulation (TMS) must also be prior authorized by the MHSA.
To be eligible to receive these benefits you must follow your approved treatment plan and
all the following authorization processes:
To obtain an authorization, call Blue Shield’s Mental Health Services Administrator
(MHSA) at 877-263-9952. You should continue to identify yourself as a Blue Shield
member and use your Blue Shield identification card and identification numbers when
contacting the MHSA or its participating providers.
Your health care provider should contact Blue Shield’s Mental Health Services
Administrator (MHSA) at 877-263-9952 to obtain information about joining the MHSA
network, obtaining an authorization for your treatment, or to speak with a member of
MHSA’s clinical staff about issues related to this benefit or your care.
Preauthorization
54 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(e)
High and Standard Option
If you would like a copy of a provider directory, you can contact the Blue Shield Member
Services Department at (800) 880-8086.
OPM will base its review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us to pay or provide one clinically
appropriate treatment plan in favor of another.
Benefit Description You Pay
Out-of-Network mental health and substance misuse disorder benefits High Option Standard
Option
Not covered out-of-network care All Charges All Charges
55 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(e)
Section 5(f). Prescription Drug Benefits
High and Standard Option
Important things you should keep in mind about these benefits:
•We cover prescribed drugs and medications, including most specialty drugs, as described in the
chart beginning on the next page.
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Members must make sure their physicians obtain prior approval/authorizations for certain
prescription drugs and supplies before coverage applies. Prior approval/authorizations must be
renewed periodically.
•Federal law prevents the pharmacy from accepting unused medications.
•We have no calendar year deductible.
•Be sure to read Section 4, Your
costs for covered services
, for valuable information about how cost-
sharing works. Also read section 9 about coordinating benefits with other coverage, including with
Medicare.
There are important features you should know about your prescription drug benefit. These include:
•Who can write your prescription? A licensed physician or dentist, and in states allowing it, licensed or certified
Physician Assistant, Nurse Practitioner and Psychologist must prescribe your medication.
•Where can you obtain your prescriptions? You must fill the prescription at a network retail pharmacy, or network mail
service pharmacy for a maintenance medication; however, specialty drugs must be filled by a Network Specialty
pharmacy. To select a Network Specialty pharmacy you may go to www.blueshieldca.com/federal or call toll-free Member
Services at (800) 880-8086.
•Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring
such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancer, and other conditions that are difficult to treat with
traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be
self-administered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by
inhalation, orally or topically. Infused or Intravenous (IV) medications are not included as Specialty Drugs. These Drugs
may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy
availability. Specialty Drugs must be considered safe for self-administration by Blue Shield’s Pharmacy & Therapeutics
Committee, be obtained from a Blue Shield Network Specialty Pharmacy and may require prior authorization for Medical
Necessity by Blue Shield. Prescriptions for specialty medications are available for up to a 30 day supply per fill only.
•We use a formulary. Prescription drug coverage is based on the use of the prescription drug formulary, a copy of which is
available to you. Medications are selected for inclusion in Blue Shield’s Outpatient Prescription Drug Formulary based on
safety, efficacy, and FDA bio-equivalency data. The Blue Shield Pharmacy and Therapeutics Committee reviews new
drugs and clinical data four times a year. Members may call Blue Shield Member Services at 800-880-8086 to find out if a
specific drug is included in the formulary. Formulary information is available on Blue Shield’s website at www.
blueshieldca.com/federal.
Selected drugs and drug dosages and most specialty drugs require prior authorization for medical necessity. You should not
become directly involved with us for this pre-authorization process. Your physician is responsible for obtaining prior
authorization and documenting medical necessity. If all necessary documentation is available from your physician, prior
authorization approval or denial will be provided to your physician within five working days of the request.
•In lieu of brand name drugs, generic drugs will be dispensed when substitution is permissible by the physician. If you
request a brand name drug when a generic drug is available, you pay the difference between the cost of the brand name
drug and its equivalent generic drug, plus the Tier 1 copayment.
56 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(f)
High and Standard Option
•Prescription Days Supply Covered: A retail Plan pharmacy may dispense up to a 30-day supply for the appropriate
copayment. Some prescriptions have specific limits on how much of the medication you can get with each prescription or
refill. This is to ensure that you receive the recommended and proper dose and length of drug therapy for your condition.
Quantity limits are based on medical necessity and appropriateness of therapy as determined by Blue Shield’s Pharmacy
and Therapeutics Committee. You will pay the appropriate copayment per prescription for out-of-state emergencies. Only
maintenance drugs are available for up to a 90-day supply at the appropriate copayment per prescription through the Plan
mail service pharmacy. Maintenance drugs are drugs commonly prescribed for six months or longer to treat a chronic
condition and are administered continuously rather than intermittently. Call Member Services at (800) 880-8086 to receive
a packet for ordering prescriptions through the mail.
If a member requires an interim supply of medication due to an active military duty assignment or if there is a national
emergency, up to a 90-day supply will be approved for covered medications. Contact Member Services at (800) 880-8086
for immediate assistance.
•Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic
name of a drug is its chemical name; the brand name is the name under which the manufacturer advertises and sells a drug.
Under federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and
effectiveness. A generic prescription costs you -- and us -- less than a brand name prescription.
••Step Therapy Step therapy is a component of prior authorization. This program requires that members must try one or
more "pre-requisite“ drug(s) first before the "step-therapy“ product will be covered. If a “prerequisite” drug is not
effective in treating the member’s condition or if it is documented that the member has previously attempted the use of one
or more step therapy prerequisite medications, then the member’s physician may apply for an exception.
Benefit Description You pay
Preventative Care medications to promote better health as
recommended by ACA
High Option Standard
Option
The following drugs and supplements are covered without cost-share, even if over-the-
counter, when prescribed by a health care professional and filled at a network
pharmacy.
• Aspirin (81mg) for adults age 50-59 and women age 55-79 and women of
childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 6 months to 12 months
• Vitamin D supplements (prescription strength) (400 units) for members 65 or older
• Pre-natal vitamins for pregnant women
• Fluoride tablets, solution (not toothpaste, rinses) for children.
Note: To receive this benefit a prescription from a doctor must be presented to
pharmacy
Preventive Medications with a USPSTF recommendation of A or B are covered without
cost-share when prescribed by a health care professional and filled by a network
pharmacy. These may include some over-the-counter vitamins, nicotine replacement
medications, and low dose aspirin for certain patients. For current recommendations go
to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations
Nothing Nothing
57 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(f)
High and Standard Option
Benefit Description You pay
Covered medications and supplies High Option Standard
Option
We cover the following medications and supplies prescribed by a Plan physician
and obtained from a retail Plan pharmacy or through our mail service pharmacy:
• Diabetic supplies limited to disposable insulin syringes, needles, pen delivery
systems for the administration of insulin as determined by Blue Shield to be
medically necessary and glucose testing tablet strips.
• Formulary and non-formulary drugs for sexual dysfunction or sexual inadequacies
will be covered when the dysfunction is caused by medically documented organic
disease. Prior Plan approval is required and the maximum dosage dispensed will be
limited by the protocols established by us. Certain drugs for these conditions are not
available through the Mail Service option.
• Drugs and medicines that by Federal law of the United States require a physician's
prescription for their purchase except those listed as
Not Covered.
• Insulin
• Diabetic supplies limited to:
- Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Inhalers and inhaler spacers for the management and treatment of asthma
• Formulary and non-formulary oral contraceptive drugs and diaphragms
Note: If the Plan allowance for the prescription at Plan pharmacies is less than the
copay, you will pay the lesser amount.
Retail (30-day
supply)
• $10 per Tier
1 retail Plan
pharmacy
prescription
• $35 per Tier
2 retail Plan
pharmacy
prescription
• 50% per
Tier 3 retail
Plan
pharmacy
prescription,
$50
minimum/
$200
maximum
• 30% per
Tier 4 retail
Plan
pharmacy
prescription,
up to $150
maximum
(excluding
specialty
drugs)
Mail Service
(up to 90-day
supply)
• $20 per Tier
1 mail
service
prescription
• $70 per Tier
2 mail
service
prescription
• 50% per
Tier 3 mail
service
prescription,
$100
minimum/
$400
maximum
Retail (30-day
supply)
• $10 per Tier
1 retail Plan
pharmacy
prescription
• $35 per Tier
2 retail Plan
pharmacy
prescription
• 50% per
Tier 3 retail
Plan
pharmacy
prescription,
$50
minimum/
$200
maximum
• 30% per
Tier 4 retail
Plan
pharmacy
prescription,
up to $150
maximum
(excluding
specialty
drugs)
Mail Service
(up to 90-day
supply)
• $20 per Tier
1 mail
service
prescription
• $70 per Tier
2 mail
service
prescription
• 50% per
Tier 3 mail
service
prescription,
$100
minimum/
$400
maximum
Covered medications and supplies - continued on next page
58 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(f)
High and Standard Option
Benefit Description You pay
Covered medications and supplies (cont.) High Option Standard
Option
• 30% per
Tier 4 mail
service
prescription,
up to $300
maximum
(excluding
specialty
drugs)
Network
Specialty
Pharmacy (up
to 30 day
supply)
• 30% per
Tier 4
prescription,
up to $150
maximum
(includes
home self-
injectable
and
specialty
drugs)
• 30% per
Tier 4 mail
service
prescription,
up to $300
maximum
(excluding
specialty
drugs)
Network
Specialty
Pharmacy (up
to 30 day
supply)
• 30% per
Tier 4
prescription,
up to $150
maximum
(includes
home self-
injectable
and
specialty
drugs)
Women's contraceptive drugs and devices
Note: Over-the-counter female contraceptive drugs and devices approved by the FDA
require a written prescription by an approved provider.
Note: If you request a brand name prescription medication over an available generic
version then you will be responsible for the Tier 1 copayment plus the difference in
price of brand name and generic drugs.
No
Copayment
No
Copayment
Smoking Cessation Medication
Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco
dependence are covered under the Smoking cessation benefit. (See page 37)
If you request a brand name prescription medication over an available generic version
then you will be responsible for the Tier 1 copayment plus the difference in price of
brand name and generic drugs.
No copay for
generic, brand
name and
over-the-
counter
tobacco
cessation
medications
when
prescribed by
a physician.
No copay for
generic, brand
name and
over-the-
counter
tobacco
cessation
medications
when
prescribed by
a physician.
Here are some things to keep in mind about our prescription drug program:
• A generic equivalent will be dispensed if it is available, unless your physician
specifically requires a brand name.
Covered medications and supplies - continued on next page
59 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(f)
High and Standard Option
Benefit Description You pay
Covered medications and supplies (cont.) High Option Standard
Option
• If you request a brand name prescription medication over an available generic
version then you will be responsible for the Tier 1 copayment plus the difference in
price of brand name and generic drugs.
Not covered:
• Drugs available without a prescription or for which there is a nonprescription
equivalent available
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
• Compounded medication with formulary alternatives or those with no FDA approved
indications
• Medical supplies such as dressings and antiseptics
• Drugs for cosmetic purposes except for Medically Necessary treatment of resulting
complications
• Drugs to enhance athletic performance
• Drugs for weight loss except when Medically Necessary for the treatment of morbid
obesity, subject to prior authorization by us.
• Vitamins, nutrients, and food supplements not listed as a covered benefit even if a
physician prescribes or administers them.
• Drugs prescribed for the treatment of dental conditions. This exclusion does not apply
to antibiotics prescribed to treat infection and medications prescribed to treat pain.
Note:
•
Intravenous fluids and medications for home use and some injectable drugs including
office injectables and injectables for the treatment of infertility are not covered under
the prescription drug benefit. Please refer to Section 5(a), 5(b) and 5(c) for coverage
information.
•
IUDs and implanted contraceptives dispensed by your physician are covered under
Section 5(a), not the Prescription Drug Benefit.
All Charges All Charges
60 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(f)
Section 5(g). Dental Benefits
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental
Plan, your FEHB Plan will be First/Primary payer of any Benefit payments and your FEDVIP Plan
is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
•Plan providers must provide or arrange your care.
•We have no calendar year deductible.
•We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient; we do not cover the
dental procedure unless it is described below.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Description You Pay
Accidental injury benefit High Option Standard
Option
The treatment of damage to natural teeth caused solely by an accidental injury is limited
to medically necessary services until the services result in initial, palliative stabilization
of the member as determined by the Plan.
Note: Dental services provided after initial stabilization, prosthodontics, orthodontia
and cosmetic services are not covered. The benefit does not include damage to the
natural teeth that is not accidental, e.g. resulting from chewing or biting.
$20 per office
visit
$50 one time
copay for
initial
stabilization
$20 per office
visit
$50 one time
copay for
initial
stabilization
Dental benefits
We have no other FEHB dental benefits.
61 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(g)
Section 5(h). Wellness and Other Special Features
High and Standard Option
Feature Description
Feature High Option Standard Option
Flexible Benefits OptionUnder the flexible benefits
option, we determine the most
effective way to provide
services.
• We may identify medically
appropriate alternatives to
regular contract benefits as a
less costly alternative. If we
identify a less costly
alternative, we will ask you
to sign an alternative benefits
agreement that will include
all of the following terms in
addition to other terms as
necessary. Until you sign and
return the agreement, regular
contract benefits will
continue.
• Alternative benefits will be
made available for a limited
time period and are subject to
our ongoing review. You
must cooperate with the
review process.
• By approving an alternative
benefit, we do not guarantee
you will get it in the future.
• The decision to offer an
alternative benefit is solely
ours, and except as expressly
provided in the agreement,
we may withdraw it at any
time and resume regular
contract benefits.
• If you sign the agreement,
we will provide the agreed-
upon alternative benefits for
the stated time period (unless
circumstances change). You
may request an extension of
the time period, but regular
contract benefits will resume
if we do not approve your
request.
Under the flexible benefits
option, we determine the most
effective way to provide
services.
• We may identify medically
appropriate alternatives to
regular contract benefits as a
less costly alternative. If we
identify a less costly
alternative, we will ask you
to sign an alternative benefits
agreement that will include
all of the following terms in
addition to other terms as
necessary. Until you sign and
return the agreement, regular
contract benefits will
continue.
• Alternative benefits will be
made available for a limited
time period and are subject to
our ongoing review. You
must cooperate with the
review process.
• By approving an alternative
benefit, we do not guarantee
you will get it in the future.
• The decision to offer an
alternative benefit is solely
ours, and except as expressly
provided in the agreement,
we may withdraw it at any
time and resume regular
contract benefits.
• If you sign the agreement,
we will provide the agreed-
upon alternative benefits for
the stated time period (unless
circumstances change). You
may request an extension of
the time period, but regular
contract benefits will resume
if we do not approve your
request.
Feature - continued on next page
62 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(h)
High and Standard Option
Feature Description
Feature (cont.) High Option Standard Option
• Our decision to offer or
withdraw alternative benefits
is not subject to OPM review
under the disputed claims
process. However, if at the
time we make a decision
regarding alternative
benefits, we also decide that
regular contract benefits, we
also decide that regular
contract benefits are not
payable, then you may
dispute our regular contract
benefits decision under the
OPM disputed claim process
(see Section 8).
• Our decision to offer or
withdraw alternative benefits
is not subject to OPM review
under the disputed claims
process. However, if at the
time we make a decision
regarding alternative
benefits, we also decide that
regular contract benefits, we
also decide that regular
contract benefits are not
payable, then you may
dispute our regular contract
benefits decision under the
OPM disputed claim process
(see Section 8).
High risk pregnanciesWe cover the prenatal diagnosis
of genetic disorders of the fetus
in high-risk pregnancy cases.
We cover the prenatal diagnosis
of genetic disorders of the fetus
in high-risk pregnancy cases.
Self-referral to specialty servicesAccess+ HMO allows you to
arrange office visits with Plan
specialists in the same Medical
Group or IPA as your primary
care physician without a
referral. A few physicians are
not Access+ HMO providers.
You are advised to refer to the
Access+ HMO
2019
Provider
Directory for Federal
Employees
to determine if your
physician participates in the
Access+ HMO self-referral
option. Members who use this
convenient feature are subject
to a $30 copayment per
specialty office visit. If the
medical condition requires
follow-up care to the same
specialist, you are encouraged
to request that the specialist
receive prior authorization from
your primary care physicians
for additional visits at the
regular office copayment of
$20 per visit.
The Access+ HMO specialist
includes:
• Examinations and
consultations;
• Conventional x-rays of the
chest and abdomen;
TRIO HMO allows you to
arrange office visits with Plan
specialists in the same Medical
Group or IPA as your primary
care physician without a
referral. A few physicians are
not TRIO HMO providers. You
are advised to refer to the TRIO
HMO
2019
Provider Directory
for Federal Employees
to
determine if your physician
participates in the TRIO HMO
self-referral option. Members
who use this convenient feature
are subject to a $30 copayment
per specialty office visit. If the
medical condition requires
follow-up care to the same
specialist, you are encouraged
to request that the specialist
receive prior authorization from
your primary care physicians
for additional visits at the
regular office copayment of
$20 per visit.
The TRIO HMO specialist
includes:
• Examinations and
consultations;
• Conventional x-rays of the
chest and abdomen;
Feature - continued on next page
63 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(h)
High and Standard Option
Feature Description
Feature (cont.) High Option Standard Option
• X-rays of bones to diagnose
suspected fractures;
• Laboratory services;
• Diagnostic or treatment
procedures that would
normally be provided with a
referral; and
• Vaccines and antibiotics.
The Access+ HMO specialist
visit does not include:
• Diagnostic imaging such as
CAT Scans, MRI or bone
density measurements;
• Services that are not covered
benefits or that are not
medically necessary;
• Services of a provider not in
the Access+ HMO or MHSA
network (see section 5(e));
• Allergy testing;
• Endoscopic procedures;
• Injectables, chemotherapy or
other infusion drugs (not
listed above);
• Infertility services;
• Emergency services;
• Urgent care services;
• Inpatient services or facility
charges;
• Services for which the
Medical Group or IPA
routinely allows the Member
to self-refer without
authorization from the
Personal Physician;
• OB/GYN services by an
obstetrician/gynecologist or
family practice physician
within the same Medical
Group/IPA as the Personal
Physician; and
• Internet-based consultations.
• X-rays of bones to diagnose
suspected fractures;
• Laboratory services;
• Diagnostic or treatment
procedures that would
normally be provided with a
referral; and
• Vaccines and antibiotics.
The TRIO HMO specialist
visit does not include:
• Diagnostic imaging such as
CAT Scans, MRI or bone
density measurements;
• Services that are not covered
benefits or that are not
medically necessary;
• Services of a provider not in
the TRIO HMO or MHSA
network (see section 5(e));
• Allergy testing;
• Endoscopic procedures;
• Injectables, chemotherapy or
other infusion drugs (not
listed above);
• Infertility services;
• Emergency services;
• Urgent care services;
• Inpatient services or facility
charges;
• Services for which the
Medical Group or IPA
routinely allows the Member
to self-refer without
authorization from the
Personal Physician;
• OB/GYN services by an
obstetrician/gynecologist or
family practice physician
within the same Medical
Group/IPA as the Personal
Physician; and
• Internet-based consultations.
Feature - continued on next page
64 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(h)
High and Standard Option
Feature Description
Feature (cont.) High Option Standard Option
NurseHelp 24/7Blue Shield of California’s
NurseHelp 24/7 provides
members with no charge,
confidential, unlimited
telephone support for
information, consultations, and
referrals for health and
psychosocial issues. Members
may obtain these services by
calling 1-877-304-0504, a 24-
hour, toll-free telephone
number. There is no charge for
these services.
Blue Shield of California’s
NurseHelp 24/7 provides
members with no charge,
confidential, unlimited
telephone support for
information, consultations, and
referrals for health and
psychosocial issues. Members
may obtain these services by
calling 1-877-304-0504, a 24-
hour, toll-free telephone
number. There is no charge for
these services.
Obesity program and educational resourcesFor members and dependants
18 years and older:
• Weight Management
program available through
MyWellvolution. Visit www.
blueshieldca.com/
mywellvolution for details
• Additional online resources
available through Health
Library (visit www.
blueshieldca.com/federal for
details)
- interactive tools
- actionsets
- decision points
• Weight Watchers discount
also available. See page 67,
"Non-FEHB benefits
available to Plan members."
For dependant members under
age 18:
• "What is Your Child's
BMI?" Interactive Online
Tool
• Online Health Library-
Video's and Articles detailing
causes and risks of childhood
obesity and the importance
of exercise, nutrition and
annual preventive health
screenings
Visit www.blueshieldca.com/
federal for details
For members and dependants
18 years and older:
• Weight Management
program available through
MyWellvolution. Visit www.
blueshieldca.com/
mywellvolution for details
• Additional online resources
available through Health
Library (visit www.
blueshieldca.com/federal for
details)
- interactive tools
- actionsets
- decision points
• Weight Watchers discount
also available. See page 67,
"Non-FEHB benefits
available to Plan members."
For dependant members under
age 18:
• "What is Your Child's
BMI?" Interactive Online
Tool
• Online Health Library-
Video's and Articles detailing
causes and risks of childhood
obesity and the importance
of exercise, nutrition and
annual preventive health
screenings
Visit www.blueshieldca.com/
federal for details
Feature - continued on next page
65 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(h)
High and Standard Option
Feature Description
Feature (cont.) High Option Standard Option
Health support programsBlue Shield of California offers
patient education and support
programs for certain diagnoses.
Programs include:
• Asthma Program
• Coronary Artery Disease
Program
• Heart Failure Program
• Diabetes Program (including
Pediatric Diabetes)
• Transplant Care
Coordination
• COPD Program
• Blue Shield Generic
Promotion Program
• MyWellvolution
• Antidepressant Medication
Management (AMM)
Program
• Catastrophic Injury Case
Management Program
• Complex Case Management
Program
• Neonatal Intensive Care Unit
(NICU) Case Management
Program
Blue Shield of California offers
patient education and support
programs for certain diagnoses.
Programs include:
• Asthma Program
• Coronary Artery Disease
Program
• Heart Failure Program
• Diabetes Program (including
Pediatric Diabetes)
• Transplant Care
Coordination
• COPD Program
• Blue Shield Generic
Promotion Program
• MyWellvolution
• Antidepressant Medication
Management (AMM)
Program
• Catastrophic Injury Case
Management Program
• Complex Case Management
Program
• Neonatal Intensive Care Unit
(NICU) Case Management
Program
66 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 5(h)
Non-FEHB benefits available to Plan members
The benefits described on this page are neither offered nor guaranteed under the contract with FEHB, but are made available
to all enrollees and family members who are members of this Plan. The cost of the benefits described on this page is not
included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out-of-
pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.
Receive Discounts through the Vision Plan Administrator (VPA) on Frames and Lenses. As a Blue Shield of California
member, you can enjoy discounts of up to 20% on the following products and services through the VPA discount program:
frames and eye glass lenses; contact lenses; photochromatic lenses; and tints and coatings.
For coverage of eye refractions through the VPA see page 34. Most of the providers in the network also agree under their
ECN agreement to offer this discount. Vision Plan Administrator provider directories can be accessed through www.
blueshieldca.com/federal or ordered by calling Blue Shield Member Service at (800) 880-8086.
To receive discounts from VPA providers you simply present your Blue Shield ID card when purchasing the products or
services listed here. You pay the participating provider's published fees - less the 20% discount. There is no need to file a
claim - you are responsible for all incurred charges.
Receive Discounts through the
mylifepath
Alternative Health Services Discount Program - Acupuncture, Chiropractic
and Massage Therapy. We offer the types of non-traditional medical services that our members want, at a generous
reduction in cost. They are available nationwide to members with a Blue Shield of California member identification card.
Members can get 25 percent off or more from the practitioner's published fees on these alternative care services. You will be
responsible for all charges remaining after the discounts are applied. For more details on all features, please call
888-999-9452 or visit our website at www.blueshieldca.com/wellnessdiscounts for health information and news about value-
added features, including discounts on memberships at Weight Watchers and 24-Hour Fitness.
Medical Care for Vacations, Business Travel and College Students. You and your eligible family members are covered for
urgent and emergency care in all 50 states while you are on vacation or business travel. There are no additional premiums for
this coverage. Away from Home Care is also available on a temporary basis for members and dependents who will be living
away from home and who need a local primary care provider. You pay office copayments, which vary from state to state ($5
to $25) for guest visits and $15 for urgent care visits. For additional information on these coverages, call 800-622-9402.
Blue Shield offers a variety of health plans for individuals and families. Or, if you are losing this Plan's coverage, you may
be eligible to apply for one of Blue Shield's individual plans if you meet the eligibility requirements. For more information
on all these health plans or to submit an online application, please visit our website at blueshieldca.com.
Benefits on this page are not part of the FEHB Contract
67 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Non-FEHB Benefits available to Plan members
Section 6. General Exclusions – Services, Drugs, and Supplies We Do not Cover
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this
brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for
specific services, such as transplants, see Section 3
When you need prior Plan approval for certain services
We do not cover the following:
•Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents)
•Services, drugs, or supplies you receive while you are not enrolled in this Plan
•Services, drugs, or supplies that are not medically necessary
•Services, drugs, or supplies not required according to accepted standards of medical, dental, or mental health practice
•Experimental or investigational services except for services for members who have been accepted into an approved
clinical trial for cancer as provided under covered services (Section 5(a)). (Also, see specifics regarding transplants in
Section 5(b))
•Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were
carried to term or when the pregnancy is the result of an act of rape or incest
•Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program
•Services, drugs, or supplies related to sexual dysfunction or sexual inadequacies (including penile prostheses) except as
provided for medically documented treatment of organically based conditions
•Services performed by a close relative (the spouse, child, brother, sister, or parent of a member) or a person who ordinarily
resides in the member’s home
•Services, drugs, or supplies you receive without charge while in active military service
68 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 6
Section 7. Filing a Claim for Covered Services
This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See
Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval),
including urgent care claims procedures. When you see Plan physicians, receive services at Plan hospitals and facilities, or
obtain your prescription drugs at Plan pharmacies, you will not have to file claims except for your annual eye examination.
Just present your Blue Shield identification card and pay your copayment or coinsurance.
There are four types of claims. Three of the four types - Urgent care claims, Pre-service claims, and Concurrent review
claims - usually involve access to care where you need to request and receive our advance approval to receive coverage for a
particular service or supply covered under this Brochure. See Section 3 for more information on these claims/requests and
Section 10 for the definitions of these three types of claims.
The fourth type - Post-service claims - is the claim for payment of benefits after services or supplies have been received.
You will also need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers
bill us directly. Check with the provider. If you need to file the claim, here is the process:
In most cases, providers and facilities file claims for you. Physicians must file on the form
CMS-1500, Health Insurance Claim Form. Facilities will file on the UB-04 form. For
claims questions and assistance, contact us at (800) 880-8086 or see our website at www.
blueshieldca.com/federal.
When you must file a claim -- such as for out-of-area care -- submit it on the CMS-1500
or a claim form that includes the information shown below. Bills and receipts should be
itemized and show:
• Covered member’s name date of birth, address, phone number and ID number
• Name and address of the physician or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payer --
such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services
Note: Canceled checks, cash register receipts, or balance due statements are not
acceptable substitutes for itemized bills.
Submit your claims to:
Blue Shield of California
Member Services
P.O. Box 272550
Chico, CA 95927
Medical and hospital
benefits
Send us all of the documents for your claim as soon as possible. You must submit the
claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.
Deadline for filing your
claim
We will notify you of our decision within 30 days after we receive the claim. If matters
beyond our control require an extension of time, we may take up to an additional 15 days
for review as long as we notify you before the expiration of the original 30-day period.
Our notice will include the circumstances underlying the request for the extension and the
date when a decision is expected.
Post-service claims
procedures
69 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 7
If we need an extension because we have not received necessary information from you,
our notice will describe the specific information required and we will allow you up to 60
days from the receipt of the notice to provide the information.
If you do not agree with our initial decision, you may ask us to review it by following the
disputed claims process detailed in Section 8 of this brochure.
You may designate an authorized representative to act on your behalf for filing a claim or
to appeal claims decisions to us. For urgent care claims, we will permit a health care
professional with knowledge of your medical condition to act as your authorized
representative without your express consent. For the purposes of this section, we are also
referring to your authorized representative when we refer to you.
Authorized
Representative
If you live in a county where at least 10 percent of the population is literate only in a non-
English language (as determined by the Secretary of Health and Human Services), we will
provide language assistance in that non-English language. You can request a copy of your
Explanation of Benefits (EOB) statement, related correspondence, oral language services
(such as telephone customer assistance), and help with filing claims and appeals
(including external reviews) in the applicable non-English language. The English
versions of your EOBs and related correspondence will include information in the non-
English language about how to access language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an
adverse benefit determination will include information sufficient to identify the claim
involved (including the date of service, the health care provider, and the claim amount, if
applicable), and a statement describing the availability, upon request, of the diagnosis and
procedure codes
Notice Requirements
70 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 7
Section 8. The Disputed Claims Process
You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For
more information about situations in which you are entitled to immediately appeal to OPM, including additional
requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan’s customer service representative at the
phone number found on your enrollment card, plan brochure, or plan website.
Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3
If you disagree
with our pre-service claim decision,
we describe the process you need to follow if you have a claim for services, referrals,
drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan
documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make
your request, please contact our Customer Service Department by calling (800) 880-8086.
Our reconsideration will take into account all comments, documents, records, and other information submitted by you
relating to the claim, without regard to whether such information was submitted or considered in the initial benefit
determination.
When our initial decision is based (in whole or in part) on medical judgment (i.e. medical necessity, experimental/
investigational), we will consult with a health care professional who has appropriate training and experience in the field of
medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or
his/hers subordinate, who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect
to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support
the denial of benefits.
Step Description
Ask us in writing to reconsider our initial decision. You must:
a) Write to us within 6 months from the date of our decision; and
b) Send your request to us at: Blue Shield of California, Member Services Department, P.O. Box 272550,
Chico, Ca 95927. You may call our member service department at (800) 880-8086; and
c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.
e) Include your email address (optional for member), if you would like to receive our decision via email.
Please note that by giving us your email, we may be able to provide our decision more quickly.
We will provide you, free of charge and in a timely manner, with any new or additional evidence considered,
relied upon, or generated by us or at our direction in connection with your claim and any new rationale for
our claim decision. We will provide you with this information sufficiently in advance of the date that we are
required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond
to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time
to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that
new evidence or rationale at the OPM review stage described in step 4.
1
In the case of a post-service claim, we have 30 days from the date we receive your request to:
a) Pay the claim or
b) Write to you and maintain our denial or.
2
71 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 8
c) Ask you or your provider for more information
You or your provider must send the information so that we receive it within 60 days of our request. We will
then decide within 30 more days.
If we do not receive the information within 60 days we will decide within 30 days of the date the information
was due. We will base our decision on the information we already have. We will write to you with our
decision
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal
Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620.
Send OPM the following information:
• A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing
your email address, you may receive OPM’s decision more quickly.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request. However, for urgent care claims, a health care professional with knowledge of your medical
condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.
3
OPM will review your disputed claim request and will use the information it collects from you and us to
decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you
must file the suit against OPM in Federal court by December 31 of the third year after the year in which you
received the disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.
You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law
governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record
that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
4
72 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 8
NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death
if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at (800)
880-8086. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can
quickly review your claim on appeal. You may call OPM's FEHB 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern
Time.
Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether
you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if
you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you
are receiving Workers' Compensation benefits.
73 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 8
Section 9. Coordinating Benefits with Medicare and Other Coverage
You must tell us if you or a covered family member has coverage under any other health
plan or has automobile insurance that pays health care expenses without regard to fault.
This is called “double coverage.”
When you have double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We, like other
insurers, determine which coverage is primary according to the National Association of
Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules
regarding the coordinating of benefits, visit our web site at www.blueshieldca.com/federal
When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary
plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not
pay more than our allowance.
When you have other
health coverage
TRICARE is the health care program for eligible dependents of military persons, and
retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE
or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under TRICARE or CHAMPVA.
• TRICARE and
CHAMPVA
We do not cover services that:
• You (or a covered family member) need because of a workplace-related illness or
injury that the Office of Workers’ Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will
cover your care.
• Workers’
Compensation
When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these State programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may
do so only at the next Open Season unless you involuntarily lose coverage under the State
program.
• Medicaid
We do not cover services and supplies when a local, State, or Federal government agency
directly or indirectly pays for them.
When other Government
agencies are responsible
for your care
Our right to pursue and receive subrogation and reimbursement recoveries is a condition
of, and a limitation on, the nature of the benefits under our coverage.
When others are
responsible for injuries
74 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Section 9
If you have received benefits or benefit payments as a result of injury or illness and you or
your representatives, heirs, administrators, successors, or assignees receive payment from
any party that may be liable, a third party's insurance policies, your own insurance
policies, or a workers' compensation program or policy, you must reimburse us out of that
payment. Our right to reimbursement extends to any payment received by settlement,
judgment, or otherwise.
We are entitled to reimbursement to the extent of the benefits we have paid or provided in
connection with your injury or illness. However, we will cover the cost of treatment that
exceeds the amount of the payment you received.
Reimbursement to us out of the payment shall take first priority (before any of the rights
of any other party are honored) and is not impacted by how the judgment, settlement, or
other recovery is characterized, designated, or apportioned. Our right of reimbursement is
not subject to attorney fee or costs under the "common fund" doctrine and is fully
enforceable regardless of whether you are "made whole" or fully compensated for the full
amount of damages claimed.
We may, at our option, chose to exercise our right of subrogation and pursue a recovery
from any liable party as a successor to your rights.
If you do pursue a claim or case related to your injury or illness, you must promptly notify
us and cooperate with our reimbursement or subrogation efforts.
Some FEHB plans already cover some dental and vision services. When you are covered
by more than one vision/dental plan, coverage provided under your FEHB plan remains as
your primary coverage. FEDVIP coverage pays secondary to that coverage. When you
enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 1-877-888-3337,
(TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so
that your plans can coordinate benefits. Providing your FEHB information may reduce
your out-of-pocket cost.
When you have Federal
Employees Dental and
Vision Insurance Plan
(FEDVIP) coverage
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial
that is conducted in relation to the prevention, detection, or treatment of cancer or other
life-threatening disease or condition and is either Federally funded; conducted under an
investigational new drug application reviewed by the Food and Drug Administration; or is
a drug trial that is exempt from the requirement of an investigational new drug
application.
If you are a participant in a clinical trial, this health plan will provide related care as
follows, if it is not provided by the clinical trial:
• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays
and scans, and hospitalizations related to treating the patient’s condition, whether the
patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests
that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs – costs related to conducting the clinical trial such as research
physician and nurse time, analysis of results, and clinical tests performed only for
research purposes. These costs are generally covered by the clinical trials. This plan
does not cover these costs.
Clinical trials
When you have Medicare
Medicare is a health insurance program for:
• People 65 years of age or older
• Some people with disabilities under 65 years of age
• What is Medicare?
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• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant)
Medicare has four parts:
• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your
spouse worked for at least 10 years in Medicare-covered employment, you should be
able to qualify for premium-free Part A insurance. (If you were a Federal employee at
any time both before and during January 1983, you will receive credit for your Federal
employment before January 1983.) Otherwise, if you are age 65 or older, you may be
able to buy it. Contact 1-800-MEDICARE (1-800-633-4227), (TTY: 1-800-486-2048)
for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement
check.
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get
your Medicare benefits. We offer a Medicare Advantage plan. Please review the
information on coordinating benefits with Medicare Advantage plans on the next page.
• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D
coverage. Before enrolling in Medicare Part D, please review the important disclosure
notice from us about the FEHB prescription drug coverage and Medicare. The notice
is on the first inside page of this brochure. For people with limited income and
resources, extra help in paying for a Medicare prescription drug plan is available. For
more information about this extra help, visit the Social Security Administration online
at www.socialsecurity.gov, or call them at 1-800-772-1213, (TTY: 1-800-325-0778).
The decision to enroll in Medicare is yours. We encourage you to apply for Medicare
benefits 3 months before you turn age 65. It’s easy. Just call the Social Security
Administration toll-free number 800-772-1213, TTY: 800-325-0778 to set up an
appointment to apply. If you do not apply for one or more Parts of Medicare, you can still
be covered under the FEHB Program.
If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal
employees and annuitants are entitled to Medicare Part A at age 65 without cost. When
you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the
coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.
Everyone is charged a premium for Medicare Part B coverage. The Social Security
Administration can provide you with premium and benefit information. Review the
information and decide if it makes sense for you to buy the Medicare Part B coverage. If
you do not sign up for Medicare Part B when you are first eligible, you may be charged a
Medicare Part B late enrollment penalty of a 10% increase in premium for every 12
months you are not enrolled. If you did not take Part B at age 65 because you were
covered under FEHBP as an active employee (or you were covered under your spouse's
group health insurance plan and he/she was an active employee), you may sign up for Part
B (generally without an increased premium) within 8 months from the time you or your
spouse stop working or are no longer covered by the group plan. You also can sign up at
any time while you are covered by the group plan.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare Advantage is the term used to describe the various private health plan choices
available to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on whether you are in the Original
Medicare Plan or a private Medicare Advantage plan.
• Should I enroll in
Medicare?
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The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share.
All physicians and other providers are required by law to file claims directly to Medicare
for members with Medicare Part B, when Medicare is primary. This is true whether or not
they accept Medicare.
When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan primary care physician.
Claims process when you have the Original Medicare Plan – You will probably not
need to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In
most cases, your claim will be coordinated automatically and we will then provide
secondary benefits for covered charges. You will not need to do anything. To find out if
you need to do something to file your claim, call us at (800) 880-8066.
We do not waive any costs if the Original Medicare Plan is your primary payer.
Please review the following table it illustrates your cost share if you are enrolled in
Medicare Part B. Medicare will be primary for all Medicare eligible services. Members
must use providers who accept Medicare's assignment.
• The Original
Medicare Plan (Part
A or Part B)
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Benefit DescriptionMember Cost without
Medicare
Member Cost with
Medicare Part B
Deductible No Deductible No Deductible
Out of Pocket Maximum Nothing after $3,000/Self
Only or $6,000/Self Plus
One or Self and Family
enrollment per year
Nothing after $3,000/Self
Only or $6,000/Self Plus
One or Self and Family
enrollment per year
Primary Care Physician $20 for Office Visit $20 for Office Visit
Specialist $20 copay, $30 Access+
HMO and TRIO HMO Self
Referral
$20 copay, $30 Access+
HMO and TRIO HMO Self
Referral
Inpatient Hospital $200 per day up to 3 days $200 per day up to 3 days
Outpatient Surgery -Hospital $250 per treatment or
surgery
$250 per treatment or
surgery
RX - Retail $10 per Tier 1 prescription
$35 per Tier 2 prescription
50% per Tier 3 prescription,
$50 minimum / $200
maximum
30% per Tier 4 prescription,
up to $150 maximum
(excluding specialty drugs)
Network Specialty
Pharmacy (up to 30-days
supply)
30% per Tier 4 prescription,
up to $150 maximum
(includes home self-
injectable and specialty
drugs)
$10 per Tier 1 prescription
$35 per Tier 2 prescription
50% per Tier 3 prescription,
$50 minimum / $200
maximum
30% per Tier 4 prescription,
up to $150 maximum
(excluding specialty drugs)
Network Specialty
Pharmacy (up to 30-days
supply)
30% per Tier 4 prescription,
up to $150 maximum
(includes home self-
injectable and specialty
drugs)
RX - Mail Order (90 day
supply)
$20 per Tier 1 prescription
$70 per Tier 2 prescription
50% per Tier 3 prescription,
$100 minimum / $400
maximum
30% per Tier 4 prescription,
up to $300 maximum
(excluding specialty drugs)
$20 per Tier 1 prescription
$70 per Tier 2 prescription
50% per Tier 3 prescription ,
$100 minimum / $400
maximum
30% per Tier 4 prescription,
up to $300 maximum
(excluding specialty drugs)
You can find more information about how our plan coordinates benefits with Medicare in
"Understanding Your Federal Options" at www.blueshieldca.com/federal.
You must tell us if you or a covered family member has Medicare coverage, and let us
obtain information about services denied or paid under Medicare if we ask. You must also
tell us about other coverage you or your covered family members may have, as this
coverage may affect the primary/secondary status of this Plan and Medicare.
• Tell us about your
Medicare coverage
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If you are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from a Medicare Advantage plan. These are private health care choices (like
HMOs and regional PPOs) in some areas of the country. To learn more about Medicare
Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY:
800-486-2048) or at www.medicare.gov.
If you enroll in a Medicare Advantage plan, the following options are available to you:
This Plan and our Medicare Advantage plan: You may enroll in our Medicare
Advantage plan and also remain enrolled in our FEHB Plan. In this case, we do not waive
cost-sharing for your FEHB coverage.
This Plan and another plan’s Medicare Advantage plan: You may enroll in another
plan’s Medicare Advantage plan and also remain enrolled in our FEHB Plan. We will still
provide benefits when your Medicare Advantage plan is primary, even out of the Medicare
Advantage plan’s network and/or service area (if you use our Plan providers). However
we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a
Medicare Advantage plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits
with Medicare.
Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your
Medicare Advantage plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB
Program, generally you may do so only at the next Open Season unless you involuntarily
lose coverage or move out of the Medicare Advantage plan’s service area.
• Medicare Advantage
(Part C)
When we are the primary payer, we process the claim first. If you enroll in Medicare Part
D and we are the secondary payer, we will review claims for your prescription drug costs
that are not covered by Medicare Part D and consider them for payment under the FEHB
plan.
• Medicare prescription
drug coverage (Part
D)
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Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates
whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can
administer these requirements correctly. (Having coverage under more than two health plans may change the order of
benefits determined on this chart.)
Primary Payor Chart
A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the
individual with Medicare is...
Medicare This Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an
annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from
the FEHB (your employing office will know if this is the case) and you are not covered under
FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded
from the FEHB (your employing office will know if this is the case) and...
• You have FEHB coverage on your own or through your spouse who is also an active
employee
• You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired
under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and
you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status
for Part B
services
for other
services
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months
or more
*
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD
(30-month coordination period)
• It is beyond the 30-month coordination period and you or a family member are still entitled
to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
• This Plan was the primary payor before eligibility due to ESRD (for 30 month
coordination period)
• Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage (TCC) and...
• Medicare based on age and disability
• Medicare based on ESRD (for the 30 month coordination period)
• Medicare based on ESRD (after the 30 month coordination period)
C. When either you or a covered family member are eligible for Medicare solely due to
disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who
is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an
annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.
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Section 10. Definitions of Terms We Use in This Brochure
January 1 through December 31 of the same year. For new enrollees, the calendar year
begins on the effective date of their enrollment and ends on December 31 of the same
year.
Calendar year
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial
that is conducted in relation to the prevention, detection, or treatment of cancer or other
life-threatening disease or condition and is either Federally funded; conducted under an
investigational new drug application reviewed by the Food and Drug Administration; or is
a drug trial that is exempt from the requirement of an investigational new drug
application.
• Routine Care Costs - costs for routine services such as doctor visits, lab tests, x-rays
and scans, and hospitalizations related to treating the patient's cancer, whether the
patient is in a clinical trial or is receiving standard therapy
• Extra Care Costs - costs related to taking part in a clinical trial such as additional tests
that a patient may need as part of the trial, but not as part of the patient's routine care
• Research Costs - costs related to conducting the clinical trial such as research
physician and nurse time, analysis of results, and clinical tests performed only for
research purposes. These costs are generally covered by the clinical trials. This plan
does not cover these costs.
Clinical Trials Cost
Categories
Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance
A copayment is a fixed amount of money you pay when you receive covered services. See
Section 4.
Copayment
Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,
coinsurance, and copayments) for the covered care you receive.
Cost-sharing
Care we provide benefits for, as described in this brochure. Covered services
Access+ HMO and TRIO HMO cover drugs, devices that are medically indicated and
biological products no longer considered to be investigational by the Food and Drug
Administration. Coverage for other procedures are reviewed by and decided by the Blue
Shield of California Medical Policy Committee. The primary criteria are that the proposed
new procedures are safe and effective.
Experimental or
investigational service
A physician or other health care professional licensed, accredited, or certified to perform
specified health services consistent with state law.
Health care professional
For the purpose of this benefit, Infertility means the Member must actively be trying to
conceive and has, with respect to a Subscriber or spouse covered here under:
1. the presence of a demonstrated bodily malfunction recognized by a licensed Doctor of
Medicine as a cause of not being able to conceive or
2. for women age 35 and less, failure to achieve a successful pregnancy (live birth) after
12 months or more of regular unprotected vaginal intercourse; or
3. for women over age 35, failure to achieve a successful pregnancy (live birth) after 6
months or more of regular unprotected vaginal intercourse; or
4. failure to achieve a successful pregnancy (live birth) after six cycles of artificial
insemination supervised by the Physician; or
5. three or more pregnancy losses.
Infertility
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Services, drugs, supplies or equipment which are medically necessary include only those
which have been established as safe and effective, are furnished under generally accepted
professional standards to treat illness, injury or medical condition, and which, as
determined by us, are:
a. consistent with standards of good medical practices in the U.S.;
b. consistent with the symptoms or diagnosis;
c. not furnished primarily for the convenience of the patient, the attending physician or
other provider; and
d. furnished at the most appropriate level, which can be provided safely and effectively to
the patient. As an inpatient, this means that your medical symptoms or conditions require
that the diagnosis, treatment or service cannot be safely provided to you as an outpatient.
Hospital Inpatient Services which are medically necessary include only those services
which satisfy the above requirements, require the acute bed-patient (overnight) setting,
and which could not have been provided in the physician's office, the outpatient
department of a hospital, or in another lesser facility without adversely affecting the
patient's condition or the quality of medical care rendered.
We reserve the right to review all claims to determine whether services are medically
necessary, and may use the services of physician consultants, peer review committees of
professional societies or hospitals, and other consultants.
Medical necessity
Plan allowance is the amount we use to determine our payment and your coinsurance for
covered services. These are negotiated lower provider rates and savings are passed on to
you. The plan allowance is the total dollar amount allowed by the Plan for Covered
Services, including the amounts payable by the Plan and payable by you.
With respect to Plan Provider and Facilities, the plan allowance is the amount that the
Provider and Blue Shield have agreed by contract will be accepted as payment in full for
the Services rendered.
Plan allowance
Any claims that are not pre-service claims. In other words, post-service claims are those
claims where treatment has been performed and the claims have been sent to us in order to
apply for benefits.
Post-service claims
Those claims (1) that require precertification, prior approval, or a referral and (2) where
failure to obtain precertification, prior approval, or a referral results in a reduction of
benefits.
Pre-service claims
A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury
and has received, in connection with that illness or injury, a payment from any party that
may be liable, any applicable insurance policy, or a workers' compensation program or
insurance policy, and the terms of the carrier's health benefits plan require the covered
indivual, as a result of such payment, to reimburse the carrier out of the payment to the
extent of the benefits initally paid or provided. The right of reimbursement is cummulative
with and not exclusive of the right of subrogation.
Reimbursement
A carrier's pursuit of a recovery from any party that may be liable, any applicable
insurance policy, or a workers' compensation program or insurance policy, as successor to
the rights of a covered individual who suffered and illness or injury and has obtained
benefits from that carrier's health benefits plan.
Subrogation
Us and we refer to Blue Shield of California Access+ HMO and TRIO HMO, or Blue
Shield's Mental Health Services Administrator (MHSA) for mental health and
substance misuse coverage.
Us/We
You refers to the enrollee and each covered family member. You
82 2019 Blue Shield of California
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A claim for medical care or treatment is an urgent care claim if waiting for the regular
time limit for non-urgent care claims could have one of the following impacts:
• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting
would subject you to severe pain that cannot be adequately managed without the care
or treatment that is the subject of the claim.
Urgent care claims usually involve Pre-service claims and not Post-service claims. We
will determine whether or not a claim is an urgent care claim by applying the judgment of
a prudent layperson who possesses an average knowledge of health and medicine.
If you believe your claim qualifies as an urgent care claim, please contact our Customer
Service Department at (800) 880-8086. You may also prove that your claim is an urgent
care claim by providing evidence that a physician with knowledge of your medical
condition has determined that your claim involves urgent care.
Urgent care claims
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Section 11. Other Federal Programs
Please note, the following programs are not part of your FEHB benefits. They are separate Federal programs that
complement your FEHB benefits and can potentially reduce your annual out-of-pocket expenses. These programs are
offered independent of the FEHB Program and require you to enroll separately with no government contribution.
First, the Federal Flexible Spending Account Program, also known as FSAFEDS, lets
you set aside pre-tax money from your salary to reimburse you for eligible dependant care
and/or health care expenses. You pay less in taxes so you save money. Participating
employees save an average of about 30% on products and services they routinely pay for
out-of-pocket.
Second, the Federal Employees Dental and Vision Insurance Program(FEDVIP)
provides comprehensive dental and vision insurance at competitive group rates. There
are several plans from which to choose. Under FEDVIP you may choose self only, self
plus one, or self and family coverage for yourself and any eligible dependents.
Third, the Federal Long Term Care Insurance Program (FLTCIP) can help cover long
term care costs, which are not covered under the FEHB Program.
Fourth, the Federal Employees’ Group Life Insurance Program (FEGLI) can help
protect your family from burdensome funeral costs and the unexpected loss of your
income.
Important information
about four Federal
programs that
complement the FEHB
Program
The Federal Flexible Spending Account Program -
FSAFEDS
It is an account where you contribute money from your salary BEFORE taxes are
withheld, then incur eligible expenses and get reimbursed. You pay less taxes so you save
money. Annuitants are not eligible to enroll.
There are three types of FSAs offered by FSAFEDS. Each type has a minimum annual
election of $100. The maximum annual election for a health care flexible spending
account (HCFSA) or a limited expense health care spending account (LEX HCFSA) is
$2,600 per person. The maximum annual election for a dependent care flexible spending
account (DCFSA) is $5,000 per household.
• Health Care FSA (HCFSA) - Reimburses you for eligible out-of-pocket health care
expenses (such as copayments, deductibles, prescriptions, physician prescribed over-
the-counter drugs and medications, vision and dental expenses, and much more) for
you and your tax dependents, including adult children (through the end of the calendar
year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of
FEHB and FEDVIP plans. This means that when you or your provider files claims
with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your
eligible out-of-pocket expenses based on the claim information it receives from your
plan.
• Limited Expense Health Care FSA (LEX HCFSA) - Designed for employees
enrolled in or covered by a High Deductible Health Plan with a Health Savings
Account. Eligible expenses are limited to out-of-pocket dental and vision care
expenses for you and your tax dependents including adult children (through the end of
the calendar year in which they turn 26).
• Dependant Care FSA (DCFSA) - Reimburses you for eligible non-medical day care
expenses for your children under age 13 and/or for any person you claim as a
dependent on your Federal Income Tax return who is mentally or physically incapable
of self-care. You (and your spouse if married) must be working, looking for work
(income must be earned during the year), or attending school full-time to be eligible
for a DCFSA.
What is an FSA?
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• If you are a new or newly eligible employee you have 60 days from your hire date to
enroll in an HCFSA or LEX HCFSA and/or DCFSA, but you must enroll before Oct 1.
if you are hired or become eligible on or after October 1 you must wait and enroll
during the Federal Benefits Open Season held each fall.
Visit www.FSAFEDS.com or call an FSAFEDS Benefits Counselor toll-free at 1-877-
FSAFEDS, 877-372-3337 (TTY, 1-866-353-8058), Monday through Friday, 9 a.m. until 9
p.m., Eastern Time.
• Where can I get more
information about
FSAFEDS?
The Federal Employees Dental and Vision Insurance Program -
FEDVIP
The Federal Employees Dental and Vision Insurance Program (FEDVIP) is, separate and
different from the FEHB Program. This Program provides comprehensive dental and
vision insurance at competitive group rates with no pre-existing condition limitations
for enrollment.
FEDVIP is available to eligible Federal and Postal Service employees, retirees, and their
eligible family members on an enrollee-pay-all basis. Employee premiums are withheld
from salary on a pre-tax basis. Beginning in 2019, FEDVIP is also available to TRICARE
eligible retirees and their families during the 2018 Federal Benefits Open Season. Active
duty family members are eligible to enroll in FEDVIP vision insurance. Both retirees and
active duty family members must be enrolled in a TRICARE health plan in order to enroll
in a FEDVIP vision plan.
Important Information
All dental plans provide a comprehensive range of services, including:
• Class A (Basic) services, which include oral examinations, prophylaxis, diagnostic
evaluations, sealants and x-rays.
• Class B (Intermediate) services, which include restorative procedures such as fillings,
prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture
adjustments.
• Class C (Major) services, which include endodontic services such as root canals,
periodontal services such as gingivectomy , major restorative services such as crowns,
oral surgery, bridges and prosthodontic services such as complete dentures.
• Class D (Orthodontic) services with up to a 12-month waiting period. Most FEDVIP
dental plans cover adult orthodontia but it may be limited. Review your FEDVIP
dental plan’s brochure for information on this benefit.
Dental Insurance
All vision plans provide comprehensive eye examinations and coverage for your choice of
either lenses and frames, or for contact lenses. Other benefits such as discounts on LASIK
surgery may also be available.
Vision Insurance
You can find a comparison of the plans available and their premiums on the OPM website
at www.opm.gov/dental and www.opm.gov/wision. These sites also provide links to each
plan's website, where you can view detailed information about benefits and preferred
providers. and
Additional Information
You enroll on the Internet at www.BENEFEDS.com. For those without access to a
computer, call 1-877-888-3337, (TTY: 1-877-889-5680).
How do I enroll?
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The Federal Long Term Care Insurance Program -
FLTCIP
The Federal Long Term Care Insurance Program (FLTCIP) can help pay for the
potentially high cost of long term care services, which are not covered by FEHB plans.
Long term care is help you receive to perform activities of daily living - such as bathing or
dressing yourself - or supervision you receive because of a severe cognitive impairment
such as Alzheimer's disease. Long term care can be received in your home, in a nursing
home, in an assisted living facility or in adult day care. You must apply, answer health
questions (called underwriting) and be approved for enrollment. Federal and U.S. Postal
Service employees and annuitants, active and retired members of the uniformed services,
and qualified relatives are eligible to apply. Your qualified relatives can apply even if you
do not. Certain medical conditions, or combinations of conditions, will prevent some
people from being approved for coverage. You must apply to know if you will be
approved for enrollment. For more information, call 800-LTC-FEDS 800-582-3337, (TTY
800 843-3557 or visit www.ltcfeds.com.
It's important protection
The Federal Employees' Group Life Insurance Program -
FEGLI
The Federal Employees’ Group Life Insurance Program (FEGLI) can help protect your
family from burdensome funeral costs and the unexpected loss of your income. You can
get life insurance coverage starting at one year’s salary to more than six times your salary
and many options in between. You can also get coverage on the lives of your spouse and
unmarried dependent children under age 22. You can continue your coverage into
retirement if you meet certain requirements. For more information, visit www.opm.gov/
life.
Peace of Mind for You
and Your Family
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Index
Allergy ...........................17-22, 27-40, 62-66
Alternative treatment ............................27-40
Ambulance ................................27-40, 48-52
Anesthesia .....................................7-8, 41-50
Autologous bone marrow transplant ...27-40
Biopsy ...................................................41-47
Blood and blood plasma .......................48-50
Breast cancer .........................................27-47
Business travel ................................13-15, 67
Cardiac rehabilitation ........................27-40
Casts ......................................................48-50
Changes for 2019 .......................................16
Chemotherapy ................27-40, 48-50, 62-66
Chiropractic ....................................27-40, 67
Claims ...4-5, 7-15, 17-22, 25-26, 62-67,
69-86
Clinical trials ..................17-22, 27-47, 74-83
Coinsurance ...13-15, 17-24, 27-40, 69-70,
74-83
College students ..............................13-15, 67
Colorectal cancer screening ..................27-40
Congenital anomalies ...........................41-47
Cost Sharing .........................................27-40
Crutches ................................................27-40
Definitions ..........27-61, 69-70, 81-83, 88-93
Dental care .................................53-55, 88-93
Dialysis ..........................27-40, 48-50, 74-80
Disposable .................................27-40, 56-60
Dressings ...................................48-50, 56-60
Durable medical equipment (DME) ...27-40
Educational classes and programs ...27-40
Effective date of enrollment .................17-22
Emergency ...13-15, 17-22, 51-60, 62-70,
88-93
Experimental or investigational ......68, 81-83
Eyeglasses .............................................27-40
Family planning ..................................27-40
Fecal occult blood test ..........................27-40
General exclusions ........................25-26, 68
Hearing services ..................................27-40
Hospice care ..............................17-22, 48-50
Hospital ...........7-22, 27-55, 61, 69-83, 88-93
Infertility ...17-24, 27-40, 56-60, 62-66,
81-83
Inhalation therapy .................................27-40
Insulin ...................................................56-60
Mail service ..............................56-60, 88-93
Massage ..........................................27-40, 67
Mastectomy ..........................................27-47
Maternity benefits .................................27-40
Medicaid ...............................................74-80
Medically necessary ...17-22, 27-66, 68,
81-83
Medicare ....................1, 27-61, 69-70, 74-80
Mental health ...17-22, 53-55, 68, 81-83,
88-93
Non-FEHB benefits .................27-40, 62-67
Nursery .............................9-12, 27-40, 48-50
Occupational therapy ..............27-40, 48-50
Office visits .........13-15, 27-40, 53-55, 62-66
Oral and maxillofacial surgery .............41-47
Orthopedic devices ...............................27-40
Out-of-pocket expenses ...23-24, 74-80,
84-86
Outpatient .......................27-60, 74-83, 88-93
Oxygen ......................................27-40, 48-50
Physical exam ...........................13-15, 27-40
Physical therapy ....................................27-50
Pregnancy ...17-22, 27-40, 62-66, 68, 81-83,
88-93
Prescription drugs ..........56-60, 69-70, 88-93
Preventive care, adult ...........................27-40
Preventive care, children ......................27-40
Prior authorization ...17-22, 27-47, 51-60,
62-66
Prostate .................................................27-40
Prosthetic devices .................................27-47
Radiation therapy ....................27-40, 48-50
Reconstructive surgery .........................41-47
Renal dialysis ........................................48-50
Room and board ....................................48-50
Second opinions .......................17-22, 27-40
Self-referral option ...............................62-66
Service area .........13-15, 17-22, 51-52, 74-80
Skilled nursing facility care ..................17-22
Speech therapy ......................................27-40
Splints ...................................................48-50
Subrogation ...........................................74-83
Substance misuse .......................53-55, 88-93
Surgery ...7-8, 17-22, 27-50, 74-80, 84-86,
88-93
Syringes ................................................56-60
Temporary Continuation of Coverage
...................................................4-5, 9-12
Transplants ..........................17-22, 27-47, 68
Treatment therapies ..............................27-40
Vision services ..........................27-40, 74-80
Wheelchairs .........................................27-40
X-rays ............................27-50, 62-66, 74-86
87 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Index
Summary of Benefits for Access+ HMO and TRIO HMO - 2019
•Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions ,
limitations, and exclusions in this brochure. You can obtain a copy of our Affordable Care Act Summary of Benefits and
Coverage at www.coveredca.com. On this page we summarize specific expenses we cover; for more detail, look inside.
•If you want to enroll or change your enrollment in these Plans, be sure to put the correct enrollment code from the cover
on your enrollment form.
•We only cover services provided or arranged by Plan physicians, except in emergencies.
High Option and Standard Option
Benefits
You pay Page
Medical services provided by physicians:
Office visit copayment: $20 primary care; $30 specialist
self-referral
27 Diagnostic and treatment services provided in
the office
Services provided by a hospital:
$200 per day up to 3 days 48 • Inpatient
$250 per treatment or surgery 49 • Outpatient
Emergency benefits:
$100 copayment per visit 52 • In-area or out-of-area
. Mental health and substance misuse
treatment:
Regular cost-sharing 53 • In-network
No Benefit 55 • Out-of-Network
Prescription drugs:
$10 per Tier 1 prescription
$35 per Tier 2 prescription
50% per Tier 3 prescription. $50 minimum / $200
maximum
30% per Tier 4 prescription, up to $150 maximum
(excluding specialty drugs)
Network Specialty Pharmacy - 30% per Tier 4
prescription, up to $150 maximum (includes home self-
injectable and specialty drugs)
58 • Retail pharmacy (30-day supply)
$20 per Tier 1 prescription
$70 per Tier 2 prescription
50% per Tier 3 prescription. $100 minimum / $400
maximum
30% per Tier 4 prescription, up to $300 maximum
(excluding specialty drugs)
58 • Mail service (90 day supply)
88 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Summary of Benefits
High Option and Standard Option
Benefits
You pay Page
Dental care:
$20 per office visit; $50 one time copay for initial
stabilization
61 • Accidental injury benefit
You pay total premiums plus various copayments 61 • Optional Non-FEHB Dental Plan
$20 per office visit 34 Vision care:
Nothing 62 Special features: Flexible benefits option,
High risk pregnancy program, Access+ HMO
and TRIO HMO self-referral, NurseHelp
24/7, Health support programs
Protection against catastrophic costs (your
catastrophic protection out-of-pocket
maximum):
Nothing after $3,000/Self Only or $6,000/Self Plus One or
Self and Family enrollment per year
Some costs do not count toward this protection.
23 • Surgical and medical
Nothing after $3,000/Self Only or $6,000/Self Plus One or
Self and Family enrollment per year
Some costs do not count toward this protection.
23 • Mental health and substance misuse
89 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Summary of Benefits
Notes
90 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Summary of Benefits
Notes
91 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Summary of Benefits
Notes
92 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Summary of Benefits
Notes
93 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Summary of Benefits
2019 Rate Information for Blue Shield of California Access+ HMO and TRIO HMO
To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.
To review premium rates for all FEHB health plan options please go to www. opm.gov/FEHBpremiums or www.opm.
gov/Tribalpremium.
Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency
that maintains your health benefits enrollment.
Postal rates apply to certain United States Postal Service employees as follows:
•Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreements:
APWU, IT/AS, NALC, NPMHU, and NRLCA.
•If you are a career bargaining unit employee represented by the agreement with NPPN, you will find your premium rates
on https://liteblue.usps.gov/fehb.
•Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement:
PPOA.
Non-Postal rates apply to all career non-bargaining unit Postal Service employees. Postal rates do not apply to non-
career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not
career Postal employees.
If you are a Postal Service employee and have questions or require assistance, please contact:
USPS Human Resources Shared Service Center: 877-477-3273, option 5, Federal Relay Service 800-877-8339
Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee
contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium.
Please contact your Tribal Benefits Officer for exact rates.
Type of Enrollment Enrollment
Code
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Gov't
Share
Your
Share
Gov't
Share
Your
Share
Category 1
Your Share
Category 2
Your Share
High Option Self
Only
SI1 $230.18 $129.49 $498.72 $280.57 $126.29 $116.70
High Option Self
Plus One
SI3 $492.27 $299.01 $1,066.59 $647.85 $292.17 $271.66
High Option Self
and Family
SI2 $525.32 $301.94 $1,138.19 $654.21 $294.64 $272.76
Standard Option
Self Only
SI4 $230.18 $95.24 $498.72 $206.36 $92.04 $82.45
Standard Option
Self Plus One
SI6 $492.27 $223.66 $1,066.59 $484.59 $216.82 $196.31
Standard Option
Self and Family
SI5 $525.32 $223.15 $1,138.19 $483.50 $215.85 $193.97
94 2019 Blue Shield of California
Access+ HMO® and TRIO HMO®
Rates
