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Effective: January 01, 2019Trio HMO planSummary of BenefitsFind your doctorGo to blueshieldca.com/triosfhss and select the type ofprovider you need. Enter your location, then clickContinue.
San Francisco Health Service SystemFund (CCSF)Effective January 1, 2019HMO Benefit PlanSummary of BenefitsSan Francisco Health Service System Custom Trio HMO 25This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California benefitPlan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage(EOC).1 Please read both documents carefully for details.Provider Network:Trio ACO HMO NetworkCalendar Year Deductibles (CYD) 2A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays forCovered Services under the benefit Plan.When using a Participating Provider3Calendar Year medical DeductibleIndividual coverageFamily coverage 0 0: individual 0: FamilyCalendar Year Out-of-Pocket Maximum4An Out-of-Pocket Maximum is the most a Member will pay for CoveredServices each Calendar Year. Any exceptions are listed in the EOC.When using a Participating Provider3Individual coverageFamily coverage 2,000 2,000: individual 4,000: FamilyA47045 (1/19) Plan ID: 49131No Lifetime Benefit MaximumUnder this benefit Plan there is no dollarlimit on the total amount Blue Shield willpay for Covered Services in a Member’slifetime.Blue Shield of California is an independent member of the Blue Shield AssociationThis benefit Plan uses a specific network of Health Care Providers, called the Trio ACO HMO provider network. MedicalGroups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers. Youmust select a Primary Care Physician from this network to provide your primary care and help you access services, butthere are some exceptions. Please review your Evidence of Coverage for details about how to access care under thisPlan. You can find Participating Providers in this network at blueshieldca.com.
Benefits5Your paymentWhen using aParticipating Provider3Preventive Health Services6 0California Prenatal Screening Program 0Physician servicesPrimary care office visit 25/visitTrio specialist care office visit (self-referral) 30/visitOther specialist care office visit (referred by PCP) 25/visitPhysician home visit 25/visitPhysician or surgeon services in an Outpatient Facility 0Physician or surgeon services in an inpatient facility 0Other professional servicesOther practitioner office visit 25/visitIncludes nurse practitioners, physician assistants, and therapists.Teladoc consultation 0Family planningCounseling, consulting, and education 0Injectable contraceptive; diaphragm fitting, intrauterinedevice (IUD), implantable contraceptive, and relatedprocedure. 0 Tubal ligation 0 Vasectomy Infertility services 75/surgery50%Podiatric services 25/visitPregnancy and maternity care6Physician office visits: prenatal and postnatal 0Physician services for pregnancy termination 0Emergency servicesEmergency room services 100/visitIf admitted to the Hospital, this payment for emergency roomservices does not apply. Instead, you pay the ParticipatingProvider payment under Inpatient facility services/ Hospitalservices and stay.Emergency room Physician services 02CYD2applies
Benefits5Your paymentWhen using aParticipating Provider3Urgent care center services 25/visitAmbulance services 50/transportThis payment is for emergency or authorized transport.Outpatient Facility servicesAmbulatory Surgery Center 100/surgeryOutpatient department of a Hospital: surgery 100/surgeryOutpatient department of a Hospital: treatment of illness or injury,radiation therapy, chemotherapy, and necessary supplies 0Inpatient facility servicesHospital services and stay 200/admissionTransplant servicesThis payment is for all covered transplants except tissue andkidney. For tissue and kidney transplant services, the payment forInpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services Physician inpatient services 200/admission 0Diagnostic x-ray, imaging, pathology, and laboratory servicesThis payment is for Covered Services that are diagnostic, nonPreventive Health Services, and diagnostic radiological procedures,such as CT scans, MRIs, MRAs, and PET scans. For the payments forCovered Services that are considered Preventive Health Services, seePreventive Health Services.Laboratory servicesIncludes diagnostic Papanicolaou (Pap) test. Laboratory center 0 Outpatient department of a Hospital 0X-ray and imaging servicesIncludes diagnostic mammography. Outpatient radiology center 0 Outpatient department of a Hospital 0Other outpatient diagnostic testingTesting to diagnose illness or injury such as vestibular functiontests, EKG, ECG, cardiac monitoring, non-invasive vascularstudies, sleep medicine testing, muscle and range of motion tests,EEG, and EMG. Office location 0 Outpatient department of a Hospital 0Radiological and nuclear imaging services Outpatient radiology center 03CYD2applies
Benefits5Your paymentWhen using aParticipating Provider3 Outpatient department of a Hospital 0Rehabilitative and Habilitative ServicesIncludes Physical Therapy, Occupational Therapy, RespiratoryTherapy, and Speech Therapy services.Office location 25/visitOutpatient department of a Hospital 25/visitDurable medical equipment (DME)DME 0Breast pump 0Orthotic equipment and devices 0Prosthetic equipment and devices 0Home health servicesUp to 100 visits per Member, per Calendar Year, by a home healthcare agency. All visits count towards the limit, including visits duringany applicable Deductible period, except hemophilia and homeinfusion nursing visits.Home health agency services 25/visitIncludes home visits by a nurse, Home Health Aide, medical socialworker, physical therapist, speech therapist, or occupationaltherapist.Home visits by an infusion nurse 25/visitHome health medical supplies 0Home infusion agency services 0Hemophilia home infusion services 0Includes blood factor products.Skilled Nursing Facility (SNF) servicesUp to 100 days per Member, per Benefit Period, except whenprovided as part of a Hospice program. All days count towards thelimit, including days during any applicable Deductible period anddays in different SNFs during the Calendar Year.Freestanding SNF 0Hospital-based SNF 0Hospice program services 0Includes pre-Hospice consultation, routine home care, 24-hourcontinuous home care, short-term inpatient care for pain andsymptom management, and inpatient respite care.4CYD2applies
Benefits5Your paymentWhen using aParticipating Provider3CYD2appliesOther services and suppliesDiabetes care services Devices, equipment, and supplies Self-management training 0 25/visitDialysis services 0PKU product formulas and Special Food Products 0Allergy serum50%Hearing services Hearing aids and equipment 0Up to 2,500 per ear, per member, per 36 months.Mental Health and Substance Use Disorder BenefitsYour paymentMental health and substance use disorder Benefits are providedthrough Blue Shield's Mental Health Services Administrator (MHSA).When using a MHSAParticipating Provider3CYD2appliesOutpatient servicesOffice visit, including Physician office visit 25/visitOther outpatient services, including intensive outpatient care,Behavioral Health Treatment for pervasive developmental disorderor autism in an office setting, home, or other non-institutional facilitysetting, and office-based opioid treatment 0Partial Hospitalization Program 0Psychological Testing 0Inpatient servicesPhysician inpatient services 0Hospital services 200/admissionResidential Care 200/admissionNotes1Evidence of Coverage (EOC):The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under thisbenefit Plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can requesta copy of the EOC at any time.Defined terms are in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of Benefits.5
Notes2Calendar Year Deductible (CYD):Calendar Year Deductible explained. A Deductible is the amount you pay each Calendar Year before Blue Shieldpays for Covered Services under the benefit Plan.If this benefit Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identifiedwith a check mark ( ) in the Benefits chart above.3Using Participating Providers:Participating Providers have a contract to provide health care services to Members. When you receive CoveredServices from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any CalendarYear Deductible has been met.Your payment for services from “Other Providers.” You will pay the Copayment or Coinsurance applicable toParticipating Providers for Covered Services received from Other Providers. However, Other Providers do not have acontract to provide health care services to Members and so are not Participating Providers. Therefore, you will alsopay all charges above the Allowable Amount. This out-of-pocket expense can be significant.4Calendar Year Out-of-Pocket Maximum (OOPM):Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges above a Benefitmaximum.Essential health benefits count towards the OOPM.Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for anindividual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM withina Calendar Year.5Separate Member Payments When Multiple Covered Services are Received:Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance)for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example,you may owe an office visit Copayment in addition to an allergy serum Copayment when you visit the doctor for anallergy shot.6Preventive Health Services:If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance forthe visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit,you may have a Copayment or Coinsurance for the visit.Benefit Plans may be modified to ensure compliance with State and Federal requirements.PENDING REGULATORY APPROVALJM0710186
San Francisco Health Service SystemCustom Access and Trio HMO PlansOutpatient Prescription Drug Coverage(For groups of 300 and above)THIS DRUG COVERAGE SUMMARY IS ADDED TO BECOMBINED WITH THE HMO OR POS PLANS UNIFORMHEALTH PLAN BENEFITS AND COVERAGE MATRIX.THE EVIDENCE OF COVERAGE AND PLANCONTRACT SHOULD BE CONSULTED FOR ADETAILED DESCRIPTION OF COVERAGE BENEFITSAND LIMITATIONS.Blue Shield of CaliforniaHighlight: 0 Calendar Year Brand Drug Deductible 10 Formulary Generic/ 25 Formulary Brand/ 50 Non-Formulary Brand Drug - Retail Pharmacy 20 Formulary Generic/ 50 Formulary Brand/ 100 Non-Formulary Brand Drug - Mail ServiceCovered ServicesMember CopaymentDEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible)Calendar Year Brand Drug DeductibleApplies to covered brand and specialty drugsPRESCRIPTION DRUG COVERAGE 1, 2, 3, 4Retail Prescriptions up to a 30-day supply) Contraceptive drugs and devices 5 Formulary Generic drugs Formulary Brand drugs Non-Formulary Brand drugsMail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 5 Formulary Generic drugs Formulary Brand drugs Non-Formulary Brand drugsSpecialty Pharmacies (up to a 30-day supply) 6 Specialty drugs 7NoneParticipating Pharmacy8 0 per prescription 10 per prescription 25 per prescription 50 per prescription 0 per prescription 20 per prescription 50 per prescription 100 per prescription20% up to1 Amounts paid through copayments and any applicable pharmacy deductible accrues to the member's medical calendar year out-of-pocket maximum. Please refer to theEvidence of Coverage and Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductiblecredit, if applicable, from the previous plan during the calendar year will not carry forward to your new plan.2 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency.3 Select drugs require prior authorization by Blue Shield for medical necessity, or when effective, lower cost alternatives are available.4 If the member requests a brand drug when a generic drug equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in costto Blue Shield between the brand drug and its generic drug equivalent.5 Contraceptive drugs and devices covered under the outpatient prescription drug benefits will not be subject to the applicable calendar year pharmacy deductible whenobtained from a participating pharmacy. If a brand contraceptive is requested when a generic equivalent is available, the member will be responsible for paying the differencebetween the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be coveredwithout a copayment.6 Network Specialty Pharmacies dispense Specialty drugs which require coordination of care, close monitoring, or extensive patient training that generally cannot be met by aretail pharmacy. Network Specialty Pharmacies also dispense Specialty drugs requiring special handling or manufacturing processes, restriction to certain Physicians orpharmacies, or reporting of certain clinical events to the FDA. Specialty drugs are generally high cost.7 Specialty Drugs are available from a Network Specialty Pharmacy. A Network Specialty Pharmacy provides specialty drugs by mail or upon member request, at an associatedretail store for pickup.8 Coinsurance is calculated based on the contracted rate. When the Participating Pharmacy’s contracted rate is less than the Member’s Copayment or Coinsurance, theMember only pays the contracted rate.An independent member of the Blue Shield Association(Up to 100 copayment maximum per prescription)
Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the Federal government for Medicare Part D (also calledcreditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain thiscoverage. However, you should be aware that if you have a subsequent break in this coverage of 83 days or more anytime after you were first eligible to enroll in a Medicareprescription drug plan, you would be subject to a late enrollment penalty in addition to your Part D premium.Important Prescription Drug InformationYou can find details about your drug coverage three ways:1. Check your Evidence of Coverage.2. Go to https://www.blueshieldca.com/bsca/pharmacy/home.sp and log onto My Health Plan from the home page.3. Call Member Services or Shield Concierge at the number listed on your Blue Shield member ID card.At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online tothe Pharmacy section of https://www.blueshieldca.com/bsca/pharmacy/home.sp and select the Drug Database and Formulary toaccess a variety of useful drug information that can affect your out-of-pocket expenses, such as: Look up non-formulary drugs with formulary or generic equivalents; Look up drugs that require step therapy or prior authorization; Find specifics about your prescription copayments; Find local network pharmacies to fill your prescriptions .TIPS!Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenancedrug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail servicepharmacy with a reduced copayment. Call the mail service pharmacy at (866) 346-7200. Members using TTY equipment can callTTY/TDD 866-346-7197.Plan designs may be modified to ensure compliance with state and Federal requirements.A16149-c (1/19) rob 082218
Additional Blue Shield Infertility BenefitsSan Francisco Health Service SystemCustom Access and Trio HMO PlansHow the Plan WorksYour health plan includes infertility benefits in addition to those listed in the Benefit Summary (Uniform Benefits and Coverage Matrix1).Coverage includes authorized professional, hospital, ambulatory surgery center, and ancillary services, as well as injectable drugs.Benefits are provided for a medically appropriate diagnostic work-up and ART (Assisted Reproductive Technology) procedures2.Coverage DetailsThe following ART procedures and associated services are limited, per lifetime as shown. Six (6) natural (without ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations Three (3) stimulated (with ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations Two (2) gamete intrafallopian transfer (GIFT), in-vitro fertilization (IVF), or zygote intrafallopian transfer (ZIFT) Intracytoplasmic sperm injection (ICSI) Assisted embryo hatching Elective single embryo transfer, including preparation of embryo for transfer Preimplantation genetic screening for embryo biopsy preimplantation genetic diagnosis (PGD) Cyropreservation of sperm/ oocytes/ embryos, including egg/embryo storage in conjunction with Gift, IVF or ZIFT, whenretrieved from a covered subscriber, spouse or domestic partner. Benefits are limited to one retrieval and one year of storageper person per lifetime.All benefits are subject to a3copayment.Health PlansHMO plans**Copayment50% of the allowable amount2 These services are covered only when authorized by Blue Shield and provided by a Participating Provider. Procedures must be consistent with established medical practice intreatment of infertility and induced fertilization.** Services provided under this benefit are not subject to any applicable calendar year medical deductible and do not accrue to the calendar year out-of-pocketmaximum. Services continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached.This is only a summary for informational purposes. It is not a contract. Please refer to the plan contract and Evidence of Coverage for adetailed description of covered benefits and limitations.PENDING REGULATORY APPROVALAn independent member of the Blue Shield Association A17275 (01/19) MS0816181 If you are an HMO member, services that diagnose and treat the cause of infertility are included in your basic plan benefits.
Chiropractic and Acupuncture BenefitsAdditional coverage for San Francisco Health Service SystemCustom Access and Trio HMO PlansBlue Shield Chiropractic and Acupuncture Care coverage lets you self refer to a network of more than 4,000 licensed chiropractorsand more than 2,500 licensed acupuncturists. Benefits are provided through a contract with American Specialty Health Plans ofCalifornia, Inc. (ASH Plans).How the Program WorksYou can visit any participating chiropractors or acupuncturists in California from the ASH Plans network without a referral from yourHMO Primary Care Physician. Simply call a participating provider to schedule an initial exam.At the time of your first visit, you'll present your Blue Shield identification card and pay only your copayment. Because participatingchiropractors and acupuncturists bill ASH Plans directly, you'll never have to file claim forms.If you need further treatment, the participating chiropractor or acupuncturist will submit a proposed treatment plan to ASH Plans formedical necessity review to continu
Outpatient radiology center 0 Outpatient department of a Hospital 0 Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of
