why should i buy a - california health insurance€¦ · * based on data from blue shield ratings...

Why should I buy a health plan?

Starting in 2014, having health

insurance is the law. So if you’re

not getting coverage through

your place of work or through

a government-sponsored

program, then you’ll have to

buy an individual or family

plan to avoid a tax penalty.

Plus, having health coverage

is an important way to help

you get care when you need

it, and you can feel more

secure that you will avoid

unmanageable expenses.

Guiding you on the road aheadSo, what’s changing in the landscape of healthcare coverage? Well, some

of the most significant provisions of the Affordable Care Act go into effect

beginning in 2014. And that means lots of changes coming your way. But you

don’t need to worry, with Blue Shield we’ll not only help you navigate your

way to a great plan, we’ll provide plain, simple explanations so you can be

sure that you’ve made an excellent choice for you and your family.

In this guide, you’ll find our new high-quality, affordable plans for individuals

and families. Not only do they comply with the Affordable Care Act, they’re

also simple to understand, because our goal is to give you clear and helpful

directions.

Before embarking on any new journey, there are bound to be a few

questions. So here’s a helpful little Q&A before we get on our way.

03

It’s true.

The Affordable Care Act

is transforming healthcare

coverage and Blue Shield will

make sure you are ready for

this change. We’ll make sure

to get you the information you

need to find a Blue Shield plan

that’s right for you.

How do I buy a plan from Blue Shield?

Blue Shield offers medical,

dental, vision, and term life

insurance* plans, as well as

a convenient dental + vision*

package. Contact your

authorized Blue Shield broker

for assistance.

* Underwritten by Blue Shield of

California Life & Health Insurance

Company (Blue Shield Life).

I’m not sure I can afford healthcare coverage. What can I do?

You may be eligible for

federal subsidies in the form of

premium/dues assistance (also

known as tax credits) to help

pay for your health coverage.

Depending on your income

level, you may also qualify for

a plan which reduces the costs

when you use services. We can

help you figure out whether

you qualify, and, if so, show

you how to get assistance

through Covered California,

a new statewide health

insurance marketplace.

What if I have a preexisting condition? Will that be a problem?

Starting in 2014, no one

can be denied coverage

for preexisting conditions.

So even if you have a pre-

existing condition, you’ll get

the same access to health

coverage as everyone else.

It’s a truly remarkable part

of the Affordable Care

Act, since it establishes an

unprecedented guarantee of

coverage to everyone, greatly

reducing the chance that an

individual or family could be

left with excessive medical

bills. And even if you have a

health condition, you won’t

be charged a higher rate

because of it.

0 1

What drives us?

First and foremost, our focus is on quality healthcare coverage at an

affordable price. But a close second is a little something we like to call

“keeping it simple.” Shopping for a health plan doesn’t have to be

complicated. That’s why we’ve mapped out our plans to be simple to

understand and compare, providing a clear path to finding the coverage

you need.

If you’re shopping around.

We’re proud to say that our plans have been selected by Covered

California across the state, so you’re sure to find high-quality and

affordable Blue Shield coverage options available to you.

You’ll find that our rates are among the lowest available whether you

buy them from Blue Shield through your broker or through the new

Covered California healthcare exchange. Our networks include many

excellent doctors and hospitals. And our members seem to like us: They

rate us 4 out of 5 stars* in overall customer satisfaction.

* Based on data from Blue Shield Ratings & Reviews data as of August 21, 2013.

Why you should ride with us

0 3

F

E

care

F

E

care

We’re on an affordability mission.

Blue Shield of California is a not-for-profit company.

Our mission is to ensure all Californians have

access to affordable health coverage. We pledge

to limit our annual net income to 2% of revenue*

and if we earn more than 2%, we’ll return the

difference to our customers and the community.

We’ve developed whole new provider networks

that are working with Blue Shield to lower costs.

These new networks make it possible to provide

you access to quality healthcare coverage with a

lower impact on your pocketbook.

*Subject to the board of directors’ approval.

You’re almost ready to roll

04

F

E

care

F

E

care

Healthcare coverage that’s loaded with options.

At Blue Shield, we can be your

one-stop shop for the entire

healthcare coverage package.

This means medical, dental, vision,

and life insurance* coverage—all

to save time and money, and all

in one place.

*Life insurance is underwritten by Blue Shield

of California Life & Health Insurance Company

(Blue Shield Life).

Find a model you can afford.

From the basic to the fully loaded, we’re proud to

offer plans designed to fit your varying budgets and

needs. And all of our plan options are compliant

with the Affordable Care Act, and align with the four

“metal” levels of coverage established by the law—

Ultimate (Platinum), Preferred (Gold), Enhanced (Silver),

and Basic (Bronze). We also offer a Get Covered

(Catastrophic) plan. But you can think of them as our

brand-new models. Each varies according to price

and amount of coverage, allowing you to find the

premium/dues, copay, and deductible combination

that’s right for you. Plus, all our plans provide coverage

for all the essential health benefits:

• Ambulatorypatientservices

• Emergencyservices

• Hospitalization

• Maternityandnewborncare

• Mentalhealthandsubstanceusedisorderservices

• Prescriptiondrugs

• Rehabilitativeandhabilitativeservices

• Laboratoryservices

• Preventiveandwellnessservices

• Pediatricservices,includingdentalandvisioncare

Regularly scheduled maintenance.

To help keep you and your family

in top shape, all of our plans

cover preventive care services at

no additional cost, even before

you meet a plan deductible.

Good prevention starts early and

continues throughout your entire

life. Even if you feel fine, going to

the doctor for checkups is part

of living a healthy lifestyle. These

covered screenings check for

problems early, before you feel

signs of sickness, and give you more

care choices with better results.

San Mateo

Santa Cruz

Ventura Los Angeles

Orange

San Diego

Riverside

San Bernadino

SantaClara

KernSan LuisObispo

Sacra-mento

Yolo

DelNorte Siskiyou

Modoc

Humboldt

Trinity ShastaLassen

MendocinoGlenn

TehamaPlumas

Lake

Monterey

Inyo

TuolumneCalaveras

Mariposa

Mono

San Benito

Colusa Sutter

Yuba

Sierra

NapaAmador

Alpine

Butte

Sonoma

Santa Barbara

Imperial

Merced

Madera

Fresno

Kings

Tulare

MarinSolano

SanJoaquin

StanislausAlameda

ContraCosta

Nevada

Placer

El Dorado

San Francisco

PPO

EPO

No Blue Shield covered California health plans are available for purchase in this county.

06

We’ve got California coveredPPO plans

Our PPO plan provides access to our Exclusive PPO Network of participating

doctors,specialists,andhospitals.Membershavethefreedomtoseeanydoctor

in this network without a referral. You even have the option to receive care from

non-participating providers, if you’re willing to pay more out of pocket.

If you don’t live in one of these counties, you may be able to purchase one of

our EPO plans available in most other areas of California. Visit blueshieldca.com/ findaplan or contact your authorized Blue Shield broker for more information.

0 77

70

A checklist before we get goingWhen it comes to healthcare coverage, everyone’s needs are unique. That’s why our

goal is to provide you with the information you need to choose a Blue Shield plan. So take

a look and find the one that will perform best for you. We can even help you find out if

you are eligible for assistance through Covered California and, if so, we will assist you with

your application.

70

Are you eligible for premium assistance?

Does your employer offer health coverage that meets the minimum value standard?** You may be eligible if the employer plan does not cover at least 60% of covered benefits on average or if the

employee share of the premium exceeds 9.5% of the employee’s income.

Do you receive Medicaid or Medicare?

Does your family make more than the annual income below?

Family Size Yearly Income

1 $45,960

2 $62,040

3 $78,120

4 $94,200

5 $110,280

6 $126,360

If you answered NO to ALL of these questions, you may qualify for premium assistance through

Covered California (in the form of tax credits), which lowers your monthly rates, and you may

qualify to purchase a plan with reduced cost-sharing amounts. Even if you think your income is

somewhat higher than these amounts, you may still qualify.

1

2

3

Help paying for coverage

Under the Affordable Care Act, eligible individuals and families can qualify for financial assistance to help

with monthly rates and out-of-pocket healthcare expenses to ensure that everyone has easier access to

quality healthcare coverage that’s affordable for them. Covered California offers financial assistance

depending on your income and family size. Take a few minutes to answer a few questions to determine

whether you may be eligible for assistance.

Your authorized Blue Shield broker can help you determine if you’re eligible and, if so, can

help you submit your application through Covered California. Call your broker to get free

and personalized assistance in helping you better understand your options.TM

0 9

Ultimate plan (Platinum level):

Our Ultimate plan offers you the lowest out-of-pocket costs for

medical services. There are no deductibles, so we start paying

for covered benefits right from the start. By paying higher

monthly premiums/dues, you’ll usually pay less when accessing

care for medical services such as doctor visits, prescription drugs,

and hospitalization.

Platinum LevelBlue Shield

Ultimate PPO90%

Blue Shield pays, on average, 90%

of covered medical expenses.

Preferred plan (Gold level):

Our Preferred plan offers good coverage with manageable

out-of-pocket costs, so it’s easier to predict additional expenses.

There are no deductibles, so Blue Shield starts paying for all

covered benefits immediately, including popular benefits such as

doctor visits, prescription drugs, and urgent care.

Gold LevelBlue Shield

Preferred PPO80%



Enhanced plan (Silver level):

Our Enhanced plan offers a good balance between your

premium and your out-of-pocket costs. You’ll receive benefits

like doctor visits and generic drugs prior to meeting an

annual deductible. Other covered medical services, such as

hospitalization, are covered after you meet the annual

medical deductible.

Silver LevelBlue Shield

Enhanced PPO70%



If your income is below 250 percent of the federal poverty level (about $60,000 for a family of four), you may

be eligible to save on costs with one of our three Enhanced cost-sharing reduction plans:

• EnhancedPPO150Subsidy



Enhanced cost-sharing reduction plans purchased through Covered California offer lower copayments,

deductibles, and out-of-pocket maximums than standard plan designs, so you'll pay less when accessing

services from participating providers.

Blue Shield or your broker can help you determine if you're eligible and, if so, can help you with submitting

your application to Covered California.

Let’s check the specs

Basic plan (Bronze level):

Our Basic plan is designed for people who want affordable

coverage with low monthly rates in exchange for a higher

deductible for protection in the event of a serious medical

emergency. Benefits like preventive care and three doctor

visits are available for a fixed copayment before meeting

the deductible.

Bronze LevelBlue Shield

Basic PPO60%



Basic for HSA plan (Bronze level):

If you’re looking for a plan with lower monthly rates and a way

to better manage your healthcare coverage spending, look to

our Basic Plan for high-deductible health plans that are Health

Savings Account* eligible. With an HSA, you can prepare for

future medical costs by contributing pre-tax money to your own

HSA for healthcare-related expenses. You’ll even enjoy preventive

care visits before meeting the deductible.

* Although most individuals who enroll in an HSA-compatible health plan are eligible

to open an HSA, you should consult with a financial adviser to determine if an HSA/

HDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs. HSAs

are offered through financial institutions. For more information about HSAs, eligibility,

and the law’s current provisions, you should ask your financial or tax adviser.

Bronze LevelBlue Shield

Basic PPO for HSA60%



Get Covered plan (Catastrophic):

This plan is designed specifically for people under age 30, or

those age 30 and above who can provide a certification that

they are without affordable coverage or are experiencing

financial hardship, and are simply looking for a low-cost option.

Itcarriesahighdeductible.Mostservicesaresubjecttothe

medical deductible; however, important benefits like preventive

care and three doctor visits are available, if necessary, for no

additional cost before meeting the deductible.

CatastrophicBlue Shield

Get Covered PPO60%



Native American plans:

In addition to the plans described in this guide, we also offer the following plans for Native Americans: Ultimate PPO Native American,

Preferred PPO Native American, Enhanced PPO Native American, Basic PPO Native American, Basic PPO for HSA Native American, and

Native American PPO 300 Subsidy. Contact your broker or Blue Shield for additional information on these plans. Visit blueshieldca.com

for more information.

11

PLAN LEVEL ULTIMATE PLATINUM

PREFERRED GOLD

ENHANCED SILVER

BASIC BRONZE

BASIC FOR HSA BRONZE

GET COVERED MINIMUM

COVERAGE

Blue Shield pays on average 90% 80% 70% 60% 60% 60%

No medical deductibles • •

Highest medical deductibles • • •

Lowest out-of-pocket cost when using medical services • •

Most expensive when using medical services • • •

Brand drugs without deductible • •

Cost-sharing reduction plan options for eligible individuals •

HSA-eligible •

Designed mainly for majoror unexpected illness • • •

Lowest monthly rates • • •

Moderate deductible amount •

Good balance between monthlyrate and out-of-pocket costs •

Comparing Blue Shield plansWhen comparing plans, it may be helpful to consider the balance of value and coverage. Here’s a handy

chart to help you compare our health plans:

21

A side-by-side comparison

ULTIMATE PLAN (PLATINUM)

PREFERRED PLAN (GOLD)

ENHANCED PLAN (SILVER)

ENHANCED 150 SUBSIDY* PLAN

(SILVER)


(SILVER)


(SILVER)

BASIC PLAN (BRONZE)

BASIC FOR HSA PLAN (BRONZE)

GET COVERED PLAN (CATASTROPHIC)

Benefits1 With participating providers, members pay1: With participating providers, members pay1:

Office visit— primary care doctor

$20 $30 $45 $3 $15 $40

$60 for first 3 visits per calendar year prior

to deductible, then $60 after deductible3

40%



Office visit—specialist doctor $40 $50 $65 $5 $20 $50 $70 40% 0%

Urgent care visit $40 $60 $90 $6 $30 $80



40%



Preventive health benefits $0 $0 $0 $0 $0 $0 $0 $0 $0

Inpatient hospitalization 10% 20% 20% 10% 15% 20% 30% 40% 0%

Outpatient surgery 10% 20% 20% 10% 15% 20% 30% 40% 0%

Lab $20 $30 $45 $3 $15 $40 30% 40% 0%

X-ray $40 $50 $65 $5 $20 $50 30% 40% 0%

Emergency room services not resulting in admission

$150 $250 $250 $25 $75 $250 $300 40% 0%

Maternity 10% 20% 20% 10% 15% 20% 30% 40% 0%

Generic drugs $5 $19 $19 $3 $5 $19 $19 40% 0%

Preferred brand drugs $15 $50 $50 $5 $15 $30 $504 40%4 0%4

Non-preferred brand drugs $25 $70 $70 $10 $25 $50 $754 40%4 0%4

Chiropractic Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered

Acupuncture (from a licensed acupuncturist)

$20 $30 $45 $3 $15 $40 $60 40% 0%

Pediatric eye exam $0 $0 $0 $0 $0 $0 $0 $0 $0

Pediatric eyeglasses $0 $0 $0 $0 $0 $0 $0 $0 $0

Calendar-year medical deductible2 $0 $0

$2,000 per individual / $4,000 per family

$0 $500 per individual /

$1,000 per family$1,500 per individual /




$12,700 per family

Calendar-year out-of-pocket maximum(includes deductible)










Calendar-year brand drug deductible

$0 $0 $250 per individual /

$500 per family$0

$50 per individual / $100 per family


$04 $04 $04

This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Benefit Summary Guide

and Important Legal Information booklets.

Some benefits are subject to a deductible. You are responsible for all charges up to the allowable amount until the deductible is met. At that point, you will be responsible for

the copayment or coinsurance for covered services as noted in the chart.

In addition to the plans described in this guide, the following plans are also offered through Covered California: Platinum PPO Native American, Preferred PPO Native American,

Enhanced PPO Native American, Basic PPO Native American, Basic PPO for HSA Native American, and Native American PPO 300 Subsidy. Please refer to blueshieldca.com

for details.

= Benefit is available prior to meeting any deductible = Benefit is subject to a deductible

41

ULTIMATE PLAN (PLATINUM)

PREFERRED PLAN (GOLD)

ENHANCED PLAN (SILVER)


(SILVER)


(SILVER)


(SILVER)

BASIC PLAN (BRONZE)

BASIC FOR HSA PLAN (BRONZE)

GET COVERED PLAN (CATASTROPHIC)

Benefits1 With participating providers, members pay1: With participating providers, members pay1:

Office visit— primary care doctor

$20 $30 $45 $3 $15 $40



40%



Office visit—specialist doctor $40 $50 $65 $5 $20 $50 $70 40% 0%

Urgent care visit $40 $60 $90 $6 $30 $80



40%



Preventive health benefits $0 $0 $0 $0 $0 $0 $0 $0 $0

Inpatient hospitalization 10% 20% 20% 10% 15% 20% 30% 40% 0%

Outpatient surgery 10% 20% 20% 10% 15% 20% 30% 40% 0%

Lab $20 $30 $45 $3 $15 $40 30% 40% 0%

X-ray $40 $50 $65 $5 $20 $50 30% 40% 0%

Emergency room services not resulting in admission

$150 $250 $250 $25 $75 $250 $300 40% 0%

Maternity 10% 20% 20% 10% 15% 20% 30% 40% 0%

Generic drugs $5 $19 $19 $3 $5 $19 $19 40% 0%

Preferred brand drugs $15 $50 $50 $5 $15 $30 $504 40%4 0%4

Non-preferred brand drugs $25 $70 $70 $10 $25 $50 $754 40%4 0%4

Chiropractic Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered

Acupuncture (from a licensed acupuncturist)

$20 $30 $45 $3 $15 $40 $60 40% 0%

Pediatric eye exam $0 $0 $0 $0 $0 $0 $0 $0 $0

Pediatric eyeglasses $0 $0 $0 $0 $0 $0 $0 $0 $0

Calendar-year medical deductible2 $0 $0


$0 $500 per individual /





$12,700 per family

Calendar-year out-of-pocket maximum(includes deductible)










Calendar-year brand drug deductible

$0 $0 $250 per individual /

$500 per family$0



$04 $04 $04

* This Blue Shield plan must be purchased through Covered California. All other Blue Shield of California medical plans displayed on this chart can be purchased through Blue Shield or Covered California.

1 The amounts indicated are a percentage of the allowable amounts. Participating providers accept Blue Shield’s allowable amounts as payment in full for covered services.

2 For family coverage, each individual must satisfy their own individual deductible, unless a combination of three or more covered family members satisfies the family deductible. This satisfies the deductible for all covered family members for the remainder of the year. This does not apply to HSA-compatible plans.

3 Visit limit is a combination of any physician office visit, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visit.

4 Brand drugs are subject to the calendar year medical deductible.

0 1551

IMHLTHYCALIFORNIA

We have much more to offer than just medical coverage.

We’re the total package. You can get comprehensive

coverage by adding dental, vision, and life insurance* plans

from Blue Shield. It’s our fully loaded options for healthcare

coverage—all in one convenient place.

Family dental and vision coverage options

Total health includes oral and vision health. If you have

children, their dental and vision needs can be covered by

one of our pediatric dental plans and the pediatric vision

benefits we include in every medical plan. But what about

you? For as little as $34.50 per month you can get complete

coverage by adding valuable family dental and vision

coverage to your medical coverage†.

* Life insurance is underwritten by Blue Shield of California Life & Health Insurance Company

(Blue Shield Life).

†Rateisfora21-year-oldenrolledintheEnhancedDentalHMO$0andUltimateVision15/25/150

plans.

Fully loaded coverage

Family vision plan options

Keep an eye on your vision health with a Blue Shield vision plan. The Ultimate Vision 15/25/150 plan* is a comprehensive vision plan that features a $150 frame allowance, and Specialty Duo* offers the convenience of dental and vision coverage in a single package. Both plans can be purchased with or without a medical plan.

Benefit ULTIMATE VISION 15/25/150SPECIALTY DUOSM

DENTAL + VISION PACKAGE

Allowance and copays with participating providers1:

EYE EXAM (every 12 months) $15 copay $0 copay

MATERIALS COPAY $25 copay $25 copay

Frames$150 allowance

(every 12 months)$100 allowance

(every 24 months)

LensesStandard single vision, lined bifocal or lined trifocal with scratch coating

$0 copay $0 copay

Lens Options and Treatments

Polycarbonate Lenses (only for Dependent children)

$100 allowance $100 allowance

Polycarbonate Lenses $160 allowance Not covered

Progressive Lenses $115 allowance Not covered

Anti-Reflective Lens Coating

$140 allowance Not covered

CONTACT LENSES2

Medically necessary $25 copay $25 copay

Elective (Cosmetic or Convenience)

$120 allowance $120 allowance

DIABETES MANAGEMENT REFERRAL $0 copay $0 copay

DENTAL BENEFITS (includes coverage for preventive, diagnostic, minor services, and major services)

NoneSee the chart on the next page

for more details



* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Ultimate Vision 15/25/150 is pending regulatory approval.

1 Participating providers accept Blue Shield’s allowable amounts as payment-in-full for covered services. There is a 90-day waiting period for all services.

2 Contact lenses may be selected in lieu of eyeglasses.

= Benefit is available prior to meeting any deductible

1 7

Family dental plan options

Protect your smile with one of our valuable dental plans, and you’ll enjoy

a broad range of benefits with access to a large network of providers. Add

vision coverage as well to save on routine care such as eye exams, glasses,

and contacts. We even offer a convenient dental + vision package—Specialty

Duo*—to make it easy for you to get the best of both worlds with one simple

purchase. All of our family dental plans can be purchased with or without a

medical plan.

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

BenefitENHANCED DENTAL PPO

50/1250

ENHANCED DENTAL PLUS PPO 50/1250

ENHANCED DENTAL PPO

25/500


DENTAL PPOENHANCED

DENTAL HMO $0

DENTAL HMO

SPECIALTY DUO DENTAL

+ VISION PACKAGE

With participating providers, members pay1:

Diagnostic and preventive services(includes but is not limited to cleanings, X-rays, initial and periodic oral examinations)

0% 0% 0% 0% $0 $0 $0 $0

Restorative services—fillings(one surface resin composite)

20%2 20%2 20%2 20%2 $373 $20 $18 $373

Oral surgery(includes but is not limited to extraction of erupted tooth or exposed root)

20%2 20%2 20%2 20%2 $403 $40 $34 $403

Root canal(anterior root canal)

50%4 50%4 50%4 50%4 $1563 $175 $155 $1563

Crowns(porcelain/ceramic substrate)

50%4 50%4 50%4 50%4 $2654 $3505 $3005 $2654

Orthodontics Not covered

50%4 (for children up to age 26

only; limitations apply6)

Not covered



$2,350 for child, fully banded,

two year4

$2,650 for adult, fully banded,

two year4


two year


two year


two year


two year


two year4


two year4

Vision coverage (includes exam, frame, lenses, and contacts benefits)

Not covered Not covered Not covered Not covered Not covered Not covered Not covered

See the family vision coverage

section on the previous

page for details

Calendar-year deductible8

$50 per individual /

$150 per family


$150 per family


$75 per family


$75 per family

$50 per individual

$0 $0 $50 per

individual

Calendar-year benefit$1,250 per individual

$1,250 per individual

$500 per individual

$500 per individual


None None$1,000 per individual

81




2 There is a six-month waiting period for these services.

3 There is a three-month waiting period for these services.

4 There is a 12-month waiting period for these services.

5 Ifpreciousmetalsareused,memberwillbechargedatthedentist’scost.ForDentalHMO,porcelainonmolarteethissubjecttoanadditionalchargeof$75.00.

6 There is a $100 deductible for orthodontia, a $500 annual maximum benefit per child per year, and a $1,000 maximum per child per lifetime.

7 There is a $50 deductible for orthodontia, a $250 annual maximum benefit per child per year, and a $500 maximum per child per lifetime.

8 Applies to all services except diagnostic and preventive services. See footnotes 6 and 7 above for deductible requirements specific to orthodontics.


BenefitENHANCED DENTAL PPO

50/1250


ENHANCED DENTAL PPO

25/500


DENTAL PPOENHANCED

DENTAL HMO $0

DENTAL HMO

SPECIALTY DUO DENTAL

+ VISION PACKAGE

With participating providers, members pay1:

Diagnostic and preventive services(includes but is not limited to cleanings, X-rays, initial and periodic oral examinations)

0% 0% 0% 0% $0 $0 $0 $0

Restorative services—fillings(one surface resin composite)

20%2 20%2 20%2 20%2 $373 $20 $18 $373

Oral surgery(includes but is not limited to extraction of erupted tooth or exposed root)

20%2 20%2 20%2 20%2 $403 $40 $34 $403

Root canal(anterior root canal)

50%4 50%4 50%4 50%4 $1563 $175 $155 $1563

Crowns(porcelain/ceramic substrate)

50%4 50%4 50%4 50%4 $2654 $3505 $3005 $2654

Orthodontics Not covered



Not covered




two year4


two year4


two year


two year


two year


two year


two year4


two year4

Vision coverage (includes exam, frame, lenses, and contacts benefits)

Not covered Not covered Not covered Not covered Not covered Not covered Not covered

See the family vision coverage

section on the previous

page for details

Calendar-year deductible8


$150 per family


$150 per family


$75 per family


$75 per family

$50 per individual

$0 $0 $50 per

individual

Calendar-year benefit$1,250 per individual


$500 per individual

$500 per individual


None None$1,000 per individual

91

Pediatric dental plans

Pediatric dental care is an essential health benefit that must be included with the purchase of every medical plan through Blue Shield

(outside of Covered California). To expand your pediatric dental benefit options, we provide you with four different pediatric dental

plans to choose from.

Pediatric dental benefits are provided only to those under age 19. Because pediatric dental care is a federally mandated essential

health benefit, every applicant (including adults) applying for a medical plan outside of the Exchange must select a pediatric dental

plan. Although individuals age 19 and older must select a pediatric dental plan, they will not be eligible for benefits and the pediatric

dental rate will not apply.

This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Benefit Summary Guide and

Important Legal Information booklets.


2 Rate is for a child under age 19 living in pricing regions 11-12 and 17-18.

3 Copayments for basic services vary by procedures. The plan’s average copay charged for procedures in this category cannot exceed the stated amount.

4 Copayments for major services vary by procedures. The plan’s average copay charged for procedures in this category cannot exceed the stated amount.

5 For families with two or more children covered under this dental plan, the out-of-pocket maximum is limited to $2,000 for all children ($1,000 per child times a maximum of two children).

BenefitPREFERRED DENTAL HMO PEDIATRIC $0

ENHANCED DENTAL HMO PEDIATRIC $20

PREFERRED DENTAL PPO PEDIATRIC 50/01

ENHANCED DENTAL PPO PEDIATRIC 60/01

Rates as low as $10.80 Rates as low as $9.60 Rates as low as $21.002 Rates as low as $18.702

With participating providers, members pay:

Office visit $0 $20 N/A N/A

Diagnostic and preventive services(includes but is not limited to cleanings, X-rays, initial and periodic oral examinations, topical fluoride treatment)

$0 $0 0% 0%

Restorative services—fillings(amalgam or composite resin)

$403 $953 20% 50%

Oral surgery (removal of impacted teeth)

Endodontics (root canal)

Periodontics (root planing/scaling)

$3654 $3654 50% 50%

Crowns and fixed bridges (includes but is not limited to crowns [resin-based composite, porcelain, porcelain with metal, full metal, gold only, three-quarter crown, stainless steel] and fixed bridges [which are cast porcelain baked with metal or plastic processed to gold])

$3654 $3654 50% 50%

Removable prosthetics (includes but is not limited to dentures [full maxillary, full mandibular, partial upper, partial lower, teeth, clasps, and stress breakers])

$3654 $3654 50% 50%

Orthodontics (medically necessary)

$1,000 $1,000 50% 50%

Local and general anesthetics $0 $0 0% 0%

Calendar-year deductible $0 $0 $50 per child / $100 per family

$60 per child / $120 per family

Calendar-year out-of-pocket maximum (includes deductible)

$1,000 per child (2 child max)5




Calendar-year benefit maximum per member

N/A N/ANo limit when using

participating providersNo limit when using

participating providers


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Individual term life insurance

Facing financial burdens after the loss of a loved one can be overwhelming, and having life insurance helps. Individual term life

insurance plans from Blue Shield Life can help safeguard the future of the significant people in your life—your spouse, partner, or

children—by providing critical financial protection that can be used to cover living expenses, college education costs, mortgage

payments, and more. Take a step toward safeguarding the financial future of those you care about by applying for life insurance

coverage from Blue Shield of California Life & Health Insurance Company.

We offer the financial protection and security of $10,000, $30,000, $60,000, $90,000, and $100,000 in term life insurance with low

monthly rates based on your age.

Age range $10,000 $30,000 $60,000 $90,000 $100,000

Available coverage amounts*

1 to 18t $1.95 $2.95 N/A N/A N/A

19 to 29 $2.75 $5.35 $9.25 $13.15 $14.45

30 to 39 $3.05 $6.25 $11.05 $15.85 $17.45

40 to 49 $5.85 $14.65 $27.85 $41.05 $45.45

50 to 59 $13.85 $38.65 $75.85 $113.05 $125.45

60 to 64 $20.45 $58.45 $115.45 $172.45 $191.45

Coverage is available to all individuals, ages 1 to 64, with or without a Blue Shield health plan. Simply complete and submit the

Application for Individual Term Life Insurance Coverage for consideration.

Download the application at blueshieldca.com/bsca/find-a-plan/life-insurance-plans or call your broker today.

* Individual term life insurance is available to applicants ages 1 to 64. All plans terminate at age 65.

t Those under age 19 are not eligible for $60,000, $90,000, or $100,000 amounts of coverage.

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To keep you and your family running strong, we’re proud to offer more than just

healthcare coverage. For no extra cost, you’ll get access to a variety of health

and wellness tools and resources to help you maintain a healthy lifestyle and get

the most out of your plan.

Blueshieldca.com

Keeping track of your coverage is just a click away. Log on to

blueshieldca.comtoaccessMyHealthPlan,whereyoucanfind

out key details such as copayment and deductible amounts,

check the status of a claim, and much more.

Online decision support tools

Take control of your health plan with our handy set of helpful

tools. Get health reports, hospital comparisons, and pharmacy

information to help you make informed decisions about your

health care.

NurseHelp 24/7 SM

Sometimes, we just need to ask a helpful human a question

about our health. Connect with a registered nurse online or

on the phone, day or night, to get immediate answers and

information for just about anything, including minor illnesses

and injuries, chronic conditions, medical tests, medications,

and preventive care.

Healthy lifestyle rewards

If you’re healthy, we don’t just applaud you, we give you tools

and resources to continue on your journey to promote a healthy

lifestyle.Useourinteractiveonlineprogram,“MyHealthAssistant

Tool,” to help reduce stress, manage your weight, quit smoking,

exercise more, eat better, and improve emotional wellness.

And take a Wellness Assessment to get recommendations on

programs you can use to track progress toward achieving your

health goals.

Bumper-to-bumper help when you need it

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* These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. Discount program

services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan. The networks of practitioners and facilities in the discount programs are

managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided

by discount program providers for medical necessity or efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the

practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered

benefits.Membersshouldaccessthosecoveredservicespriortousingthediscountprogram.Memberswhoarenotsatisfiedwithproductsorservicesreceivedfromthediscount

program may use Blue Shield’s grievance process described in the Grievance Process section of the Evidence of Coverage or Certificate of Insurance. Blue Shield reserves the

right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

•Discount Vision Program and MESVisionOptics.com—MESVision

•Weight control—Weight Watchers North America

•Fitness facilities—24 Hour Fitness, ClubSport, and Renaissance ClubSport

•LASIK—QualSight Inc., and NVISION Lasik Laser Eye Centers

•My2020EyesDirect.com—Advanced Digital Eyewear Inc

Wellness discounts*

We won’t give you a gold medal for being the fittest of the fit.

But for no additional cost, we do offer member discounts on

programs to help you pursue a healthy lifestyle:

24 Hour Fitness—Discounts on monthly dues and initiation costs,

plus no enrollment or processing fees.

ClubSport and Renaissance ClubSport—Membershipdiscounts.

Weight Watchers—Meetingvouchers,discountsononline

subscriptions, and more.

Alternative Care Discount Program—Up to 25% off on care from

participating acupuncture, chiropractic, and massage therapy

practitioners, plus discounts on health and wellness products,

including free shipping on most items.

Discount Vision Program—All Blue Shield members can save

20% on the services and materials listed below at participating

providers whether or not they have vision care benefits through

Blue Shield. Learn about participating providers on the Find a

Provider page at blueshieldca.com/fap.

• Routineeyeexams

•Framesandlenses(includingphotochromic)

•Tintsandcoatings

•Extrapairofglasses

•Non-prescriptionsunglasses

•Hardcontactlenses

To learn more about the wellness programs included

alongside any Blue Shield plan, please visit blueshieldca.com/wellnessdiscounts.

2 3

Before we hand over the keys...Here are a few key terms that'll help guide you on the road ahead.

With all the talk about “deductibles” and “copayments,” health care can sound like a foreign language. Here’s a helpful “translation” of important words to help you better understand how health plans work.

Brand drug A drug produced and sold under the original manufacturer’sbrandname.Manybranddrugs are included in the Blue Shield Drug Formulary.

Coinsurance A percentage of the cost for covered services that a member pays under the health plan.

Copayment (or copay) A fixed dollar amount that a member pays for covered services under the health plan.

Deductible The amount that a member pays for most covered services before the health plan pays for covered services.

Evidence of Coverage The contract that defines the terms of health plan coverage.

Non-participating provider A physician, hospital, or other licensed healthcare provider that is not contracted with Blue Shield to provide services to members in a Blue Shield of California or Blue Shield of California Life & Health Insurance Company PPO plan (also called a non-network provider).

Out-of-pocket maximumThe dollar limit on the amount a member has to pay for specified covered services in a calendar year.

For additional definitions, or for the contractual definitions of terms, ask for a copy of the Evidence of Coverage or Policy.

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From all of us at Blue Shield of California,

we wish you a happy and healthy road ahead.

Join Blue Shield for the road ahead.

Visit us at blueshieldca.com.

Blue Shield of California is an independent member of the Blue Shield Association OA44197-PPO (1/14)

Covered California is a registered trademark of the State of California.

why should i buy a - california health insurance€¦ · * based on data from blue shield ratings...

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