Blue Shield of California: Local Access+ HMO Premier 35 Coverage ...

Blue Shield of California: Local Access+ HMO Premier 35 Coverage Period: 7/1/2012-6/30/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Family | Plan Type: HMO
Common
Medical Event
If you are pregnant
Services You May Need
Mental/Behavioral health inpatient services
Your Cost If
You Use a
Preferred
Provider
$350/day (up to 3
days maximum per
admission)
Your Cost If
You Use a Non-
Preferred
Provider
Not covered
Substance use disorder outpatient services $25/visit Not covered
Limitations & Exceptions
Prior authorization is required. Failure
to obtain prior authorization may
result in an additional penalty or nonpayment.
Up to 20 visits per Calendar Year
combined with Mental/Behavioral
health outpatient services.
Substance use disorder inpatient services Not covered Not covered ––––––––––none––––––––––
Prenatal and postnatal care No charge Not covered ––––––––––none––––––––––
$350/day (up to 3
Delivery and all inpatient services
days maximum per Not covered ––––––––––none––––––––––
admission)
Home health care $35/visit Not covered
Prior authorization is required for up
to 100 visits per Calendar Year. Failure
to obtain prior authorization may
result in an additional penalty or nonpayment.
Rehabilitation services $35/visit Not covered ––––––––––none––––––––––
Habilitation services $35/visit Not covered ––––––––––none––––––––––
If you need help
recovering or have
Prior authorization is required for up
other special health
to 100 visits per Calendar Year. Failure
needs
Skilled nursing care $150/day Not covered to obtain prior authorization may
result in an additional penalty or nonpayment.
Durable medical equipment 50% co-insurance Not covered ––––––––––none––––––––––
Hospice service $150/day Not covered
Prior authorization is required. Failure
to obtain prior authorization may
result in an additional penalty or nonpayment.
If your child needs Eye exam N/A Not covered ––––––––––none––––––––––
Questions: Call 1-800-424-6521 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
4 of 8
at www.cciio.cms.gov or call 1-866-444-3272 to request a copy. A42426-SBC (7/12)