No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit 20% ✔ 40% ✔ Specialist care office visit 20% ✔ 40% ✔ Physician home visit 20% ✔ 40% ✔ Physician or surgeon services in an Outpatient Facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 20% 20% 20% $0 $0 $0 $0 20% 20% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 20% 20% ✔✔ ✔✔ Emergency Services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 20% ✔ ✔ $150/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 20% ✔ 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility services 40% Ambulatory Surgery Center 10% ✔ Subject to a Benefit maximum ✔ of $350/day 40% Outpatient Department of a Hospital: surgery 20% ✔ Subject to a Benefit maximum ✔ of $350/day Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 40% Subject to a Benefit maximum of $350/day ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 20% 20% 20% ✔ 40% Subject to a Benefit maximum of $600/day ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician services 20% 20% 20% ✔✔✔ Not covered Not covered Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Laboratory services • Laboratory center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 20% 20% ✔ 40% ✔ 40% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies DME 20% ✔ 40% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 20% ✔ 40% ✔ Prosthetic equipment and devices 20% ✔ 40% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 20% ✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 40% ✔ 20% ✔ 40% Subject to a Benefit maximum of $600/day ✔ Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% ✔ 40% ✔ 20% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Allergy serum billed separately from an office visit 20% ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 20% ✔ 40% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% ✔ 40% ✔ Partial Hospitalization Program 20% ✔ 40% Subject to a Benefit maximum of $350/day ✔ Psychological Testing 20% ✔ 40% ✔ Physician inpatient services $0 ✔ 40% ✔ 40% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered 30% $0 ✔ Primary care office visit 2010% ✔ 4030% ✔ Specialist care office visit 2010% ✔ 4030% ✔ Physician home visit 2010% ✔ 4030% ✔ Physician or surgeon services in an Outpatient Facility 2010% ✔ 4030% ✔ Physician or surgeon services in an inpatient facility 2010% ✔ 4030% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 30 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 2010% 20✔ 30% 20✔ 10% ✔ 30% ✔ 10% ✔ 30% ✔ $0 $0 $0 $0 20% 20% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered $0 30% ✔ $0 30% ✔ $0 30% ✔ 10% ✔ Not covered 10% ✔ 4030% ✔ Pregnancy and maternity care 4030% 4030% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 2010% 2010% ✔✔ ✔✔ Emergency Services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 2010% ✔ ✔ $150/visit plus 20% 2010% ✔ 10% ✔ 10% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 2010% ✔ 4030% ✔ Ambulance services This payment is for emergency or authorized transport. 2010% ✔ 2010% ✔ Outpatient Facility services 4030% Ambulatory Surgery Center 10% ✔ Subject to a Benefit maximum ✔ of $350/day 4030% Outpatient Department of a Hospital: surgery 2010% ✔ Subject to a Benefit maximum ✔ of $350/day Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 2010% ✔ 4030% Subject to a Benefit maximum of $350/day ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 2010% 2010% 2010% ✔ 4030% Subject to a Benefit maximum of $6001,000/day ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician services 2010% 2010% 2010% ✔✔✔ Not covered Not covered Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Laboratory services • Laboratory center 2010% ✔ 4030% ✔ 4030% • Outpatient Department of a Hospital 3010% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center 2010% ✔ 4030% ✔ 4030% • Outpatient Department of a Hospital 3010% ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location 2010% ✔ 4030% ✔ 4030% • Outpatient Department of a Hospital 3010% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 2010% ✔ 4030% ✔ 4030% • Outpatient Department of a Hospital $100/visit plus 2010% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 2010% 2010% ✔ 4030% ✔ 4030% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies DME 2010% ✔ 4030% ✔ Breast pump $0 Not covered 30% ✔ Glucose monitor 2010% 4030% ✔ Peak Flow Meter 2010% 4030% ✔ Orthotic equipment and devices 2010% ✔ 4030% ✔ Prosthetic equipment and devices 2010% ✔ 4030% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 2010% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 2010% ✔ Not covered 2010% ✔ Not covered 2010% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 2010% ✔ 4050% ✔ 2010% ✔ 4030% Subject to a Benefit maximum of $6001,000/day ✔ Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies 10% ✔ 30% ✔ • Self-management training 20% ✔ 40% ✔ 20% ✔ 40% ✔ Dialysis services PKU product formulas and special food products Allergy serum billed separately from an office visit Hearing aid services • Hearing aids and equipment When using a Participating Provider3 10% 10% 10% 10% 20% CYD2 applies When using a CYD2 applies Non-Participating applies Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Allergy serum billed separately from an office visit 20% ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 2010% ✔ 4030% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 2010% ✔ 4030% ✔ Partial Hospitalization Program 2010% ✔ 4030% Subject to a Benefit maximum of $350/day ✔ Psychological Testing 2010% ✔ 4030% ✔ Physician inpatient services $0 ✔ 4030% ✔ 4030% Hospital services 2010% ✔ Subject to a ✔ Benefit maximum of $1,000/day 30% Residential Care 10% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $6001,000/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $2540/prescription Tier 3 Drugs $4060/prescription Tier 4 Drugs 30% up to$250/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 25% plus $60/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75120/prescription Tier 3 Drugs $120180/prescription Tier 4 Drugs 30% up to $750to$750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $5080/prescription Tier 3 Drugs $80120/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit $20% ✔ /visit 40% ✔ Specialist care office visit $20% ✔ /visit 40% ✔ Physician home visit $20% ✔ /visit 40% ✔ Physician or surgeon services in an Outpatient Facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services $20% 20% 20% /visit $25/visit $25/visit $0 $0 $0 $0 20% $20% ✔ /visit 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 20% 20% ✔✔ ✔✔ Emergency Services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150100/visit plus 20% 20% ✔ ✔ $150100/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services $20% ✔ /visit 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility services 40% Ambulatory Surgery Center 1020% ✔ Subject to a Benefit maximum ✔ of $350/day 40% Outpatient Department of a Hospital: surgery 20% ✔ Subject to a Benefit maximum ✔ of $350/day Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 40% Subject to a Benefit maximum of $350/day ✔ Inpatient facility services Hospital services and stay $100/admission plus 20% ✔ 40% Subject to a Benefit maximum of $600/day ✔ Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services $100/admission plus 20% ✔ Not covered • Physician inpatient services 20% 20% ✔ Not covered Inpatient facility services $100/admission plus 20% ✔ 40Not covered Outpatient Facility services 20% Subject to a Benefit maximum of $600/day ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician services 20% 20% 20% ✔✔✔ Not covered Not covered Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Laboratory services • Laboratory center $20% /visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% $60/visit ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center $20% /visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% $60/visit ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location $20% /visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% $60/visit ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 20% 20% $35/visit $35/visit ✔ 40% ✔ 40% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies DME 20% ✔ 40% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 20% ✔ 40% ✔ Prosthetic equipment and devices 20% ✔ 40% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 20% ✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 4020% ✔ 20% ✔ 40% Subject to a Benefit maximum of $600/day ✔ Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% $20/visit ✔ 40% ✔ 20% ✔ 40% ✔ Dialysis services PKU product formulas and special food products Allergy serum billed separately from an office visit When using a Participating Provider3 20% 20% 20% CYD2 applies When using a CYD2 applies Non-Participating applies Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Allergy serum billed separately from an office visit 20% ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit $20% ✔ /visit 40% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% ✔ 40% ✔ Partial Hospitalization Program 20% ✔ 40% Subject to a Benefit maximum of $350/day ✔ Psychological Testing 20% ✔ 40% ✔ Inpatient services Physician inpatient services Hospital services Residential Care $0 $100/admission plus 20% $100/admission plus 20% ✔ 40% ✔ 40% Hospital services 20✔ Subject to a ✔ Benefit maximum of $600/day 40% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Non- Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit 2010% ✔ 4030% ✔ Specialist care office visit 2010% ✔ 4030% ✔ Physician home visit 2010% ✔ 4030% ✔ Physician or surgeon services in an Outpatient Facility 20outpatient facility 10% ✔ 4030% ✔ Physician or surgeon services in an inpatient facility 2010% ✔ 4030% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 24 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, ; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 2010% 20✔ 30% 20✔ 10% ✔ 30% ✔ 10% ✔ 30% ✔ $0 $0 $0 $0 20% 20% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered $0 Not covered $0 Not covered $0 Not covered 10% ✔ Not covered 10% ✔ 4030% ✔ Pregnancy and maternity care 40care7 30% 4030% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 2010% 2010% ✔✔ ✔✔ Emergency Services services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 2010% ✔ ✔ $150/visit plus 20% 2010% ✔ 10% ✔ 10% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Non- Participating Provider4 CYD2 applies Urgent care center services 2010% ✔ 4030% ✔ Ambulance services This payment is for emergency or authorized transport. 2010% ✔ 2010% ✔ Outpatient Facility facility services 40% Ambulatory Surgery Center 10% ✔ Subject 30% of up to a Benefit maximum ✔ of $350/day 40plus 100% of additional charges ✔ Outpatient Department of a Hospital: surgery 2010% ✔ Subject 30% of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 2010% ✔ 4030% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 2010% 2010% 2010% ✔ 4030% Subject of up to a Benefit maximum of $600/day plus 100% of additional charges ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility outpatient facility services and outpatient Outpatient Physician services payments apply. Inpatient facility services Outpatient Facility facility services Physician services 2010% 2010% 20% ✔✔✔ Not covered Not covered Physician services When using a Participating Provider3 10% CYD2 applies ✔ When using a Non- Participating Provider4 Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non-Preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. • Laboratory center • Outpatient Department of a Hospital X-ray and imaging services Includes diagnostic mammography. • Outpatient radiology center • Outpatient Department of a Hospital 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 motion tests, EEG, and EMG. • Office location • Outpatient Department of a Hospital Radiological and nuclear imaging services • Outpatient radiology center • Outpatient Department of a Hospital 10% 10% 10% 10% 10% 10% 10% 10% ✔ 30% ✔ ✔ 30% of up to $350/day plus 100% of additional charges ✔ ✔ 30% ✔ ✔ 30% of up to $350/day plus 100% of additional charges ✔ ✔ 30% ✔ ✔ 30% of up to $350/day plus 100% of additional charges ✔ ✔ 30% ✔ ✔ 30% of up to $350/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non-Non- Participating Provider4 CYD2 applies Laboratory services • Laboratory center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location Outpatient Department of a Hospital 2010% 2010% ✔ 4030% ✔ 40✔ 30% ✔ Subject of up to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies plus 100% of additional charges ✔ DME 2010% ✔ 4030% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 2010% ✔ 4030% ✔ Prosthetic equipment and devices 2010% ✔ 4030% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 2010% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 2010% 10% 10% ✔ ✔✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit periodBenefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 2010% ✔ 4010% ✔ 2010% ✔ 4030% Subject of up to a Benefit maximum of $600/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non- Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-24- hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% ✔ 40% ✔ 20% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Special Food Products Allergy serum billed separately from an office visit 20Hearing services • Hearing aids and equipment Up to $2,500 combined maximum per Member, per 36-month. 10% 10% 10% 10% 10% 10% ✔ 4030% ✔ ✔ 30% ✔ 30% of up to $350/day ✔ plus 100% of ✔ additional charges ✔ 10% ✔ ✔ 30% ✔ ✔ 10% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 2010% ✔ 4030% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 2010% ✔ 4030% ✔ Partial Hospitalization Program 2010% ✔ 4030% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Psychological Testing 2010% ✔ 4030% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Physician inpatient services $0 ✔ 4010% ✔ 4030% ✔ Hospital services 2010% ✔ Subject 30% of up to a Benefit maximum ✔ of $600/day 40plus 100% of additional charges ✔ Residential Care 2010% ✔ Subject 30% of up to a Benefit maximum ✔ of $600/day plus 100% of additional charges ✔ Prescription Drug Benefits8,9 When using a Participating Pharmacy3 CYD2 applies When using a Non-Non- Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs $0 $10/prescription Tier 2 Drugs $2535/prescription Tier 3 Drugs $4060/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750200/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $2535/prescription ✔ ✔ 25% plus $4060/prescription ✔ ✔ 30% up to $250200/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs $0 $20/prescription Tier 2 Drugs $5070/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500120/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered Benefits8,9 When using a Participating Pharmacy3 Tier 4 Drugs 30% up to $400/prescription CYD2 applies ✔ When using a Non- Participating Pharmacy4 Not covered CYD2 applies Applicable Tier 1, Tier 2, Tier 3, or Tier Oral Anticancer Drugs 4 Copayment up to $200/prescription Per prescription, up to a 30-day supply. ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit 20% ✔ $35/visit 40% ✔ Specialist care office visit 20% ✔ $35/visit 40% ✔ Physician home visit 20% ✔ $35/visit 40% ✔ Physician or surgeon services in an Outpatient Facility outpatient facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, ; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 20% 20% 20% $35/visit $25/visit $25/visit $0 $0 $0 $0 20% 20$35/visit 40% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 20% 20% ✔✔ ✔✔ Emergency Services services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 20% ✔ ✔ $150/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 20% ✔ $35/visit 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility facility services 40% Ambulatory Surgery Center 10% ✔ Subject 40% of up to a Benefit maximum ✔ of $350/day 40plus 100% of additional charges ✔ Outpatient Department of a Hospital: surgery 2025% ✔ Subject 40% of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 40% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 20% 20% 20% ✔ 40% Subject of up to a Benefit maximum of $600/day plus 100% of additional charges ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility outpatient facility services and outpatient Outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician facility services 20% 20% 2025% ✔✔✔ Not covered Not covered Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Physician services 20% ✔ Not covered Laboratory services Includes diagnostic Papanicolaou (Pap) test. • Laboratory center 20% $35/visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30$60/visit ✔ 40% ✔ Subject of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ X-ray and imaging services Includes diagnostic mammography. • Outpatient radiology center 20% $35/visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30$60/visit ✔ 40% ✔ Subject of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ 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 motion tests, EEG, and EMG. • Office location 20% $35/visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30$60/visit ✔ 40% ✔ Subject of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 2030% ✔ Subject 40% of up to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department plus 100% of a Hospital 20% 20% additional charges ✔ 40% ✔ 40% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Rehabilitative and Habilitative Services Includes Physical Therapy, Occupational Therapy, Respiratory Therapy, and Speech Therapy services. Office location Outpatient Department of a Hospital $35/visit $35/visit ✔ 40% ✔ ✔ 40% of up to $350/day plus 100% of additional charges ✔ DME 20% ✔ 40% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 20% ✔ 40% ✔ Prosthetic equipment and devices 20% ✔ 40% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 20% ✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit periodBenefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 40% ✔ 20% ✔ 40% Subject of up to a Benefit maximum of $600/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% ✔ 40% ✔ 20% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Special Food Products Allergy serum billed separately from an office visit 20% $35/visit 20% 20% 20% ✔ 40% ✔ 40% ✔ 40% of up to $350/day ✔ plus 100% of ✔ additional charges ✔ 20% ✔ ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 20% ✔ $35/visit 40% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% ✔ 40% ✔ Partial Hospitalization Program 20% ✔ 40% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Psychological Testing 20% ✔ 40% ✔ Inpatient services Physician inpatient services $0 ✔ 40% ✔ 40% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.✔
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit 20% ✔ 4050% ✔ Specialist care office visit 20% ✔ 4050% ✔ Physician home visit 20% ✔ 4050% ✔ Physician or surgeon services in an Outpatient Facility 20% ✔ 4050% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 4050% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 20% 20% 20% $0 $0 $0 $0 20% 20% ✔ 4050% ✔ ✔ 4050% ✔ ✔ 4050% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 4050% ✔ Pregnancy and maternity care 4050% 4050% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 20% 20% ✔✔ ✔✔ Emergency Services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 20% ✔ ✔ $150/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 20% ✔ 4050% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility services 4050% Ambulatory Surgery Center 10% ✔ Subject to a Benefit maximum ✔ of $350/day 4050% Outpatient Department of a Hospital: surgery 20% ✔ Subject to a Benefit maximum ✔ of $350/day Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 4050% Subject to a Benefit maximum of $350/day ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 20% 20% 20% ✔ 4050% Subject to a Benefit maximum of $600/day ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician services 20% 20% 20% ✔✔✔ Not covered Not covered Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Laboratory services • Laboratory center 20% ✔ 4050% ✔ 4050% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center 20% ✔ 4050% ✔ 4050% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location 20% ✔ 4050% ✔ 4050% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 4050% ✔ 4050% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 20% 20% ✔ 4050% ✔ 4050% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies DME 20% ✔ 4050% ✔ Breast pump $0 Not covered Glucose monitor 20% 4050% ✔ Peak Flow Meter 20% 4050% ✔ Orthotic equipment and devices 20% ✔ 4050% ✔ Prosthetic equipment and devices 20% ✔ 4050% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 20% ✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 4050% ✔ 20% ✔ 4050% Subject to a Benefit maximum of $600/day ✔ Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% ✔ 4050% ✔ 20% ✔ 4050% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 4050% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Allergy serum billed separately from an office visit 20% ✔ 4050% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 20% ✔ 4050% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% ✔ 4050% ✔ Partial Hospitalization Program 20% ✔ 4050% Subject to a Benefit maximum of $350/day ✔ Psychological Testing 20% ✔ 4050% ✔ Physician inpatient services $0 ✔ 4050% ✔ 4050% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 4050% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Non- Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit $20% ✔ 40/visit 30% ✔ Specialist care office visit 20% ✔ $40/visit 30% ✔ Physician home visit $20% ✔ 40/visit 30% ✔ Physician or surgeon services in an Outpatient Facility 20outpatient facility 10% ✔ 4030% ✔ Physician or surgeon services in an inpatient facility 2010% ✔ 4030% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 24 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, ; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services $20/visit 10% $20% 20% /visit $0 $0 $0 $0 2010% 20$40/visit 30% ✔ 4030% ✔ ✔ 4030% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 4030% ✔ Pregnancy and maternity care 40care7 30% 4030% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 2010% 2010% ✔✔ ✔✔ Emergency Services services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 2010% 20% ✔ ✔ $150/visit plus 2010% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Non- Participating Provider4 CYD2 applies Urgent care center services $20% ✔ 40/visit 30% ✔ Ambulance services This payment is for emergency or authorized transport. 2010% ✔ 2010% ✔ Outpatient Facility facility services 40% Ambulatory Surgery Center 10% ✔ Subject 30% of up to a Benefit maximum ✔ of $350/day 40plus 100% of additional charges ✔ Outpatient Department of a Hospital: surgery 2010% ✔ Subject 30% of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 2010% ✔ 4030% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 2010% 2010% 2010% ✔ 4030% Subject of up to a Benefit maximum of $600/day plus 100% of additional charges ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility outpatient facility services and outpatient Outpatient Physician services payments apply. Inpatient facility services Outpatient Facility facility services Physician services 2010% 2010% 20% ✔✔✔ Not covered Not covered Physician services When using a Participating Provider3 10% CYD2 applies ✔ When using a Non- Participating Provider4 Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non-Preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. • Laboratory center • Outpatient Department of a Hospital X-ray and imaging services Includes diagnostic mammography. • Outpatient radiology center • Outpatient Department of a Hospital 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 motion tests, EEG, and EMG. • Office location • Outpatient Department of a Hospital Radiological and nuclear imaging services • Outpatient radiology center • Outpatient Department of a Hospital $0 $0 $0 $0 $0 $0 10% 10% 30% ✔ 30% of up to $350/day plus 100% of additional charges ✔ 30% ✔ 30% of up to $350/day plus 100% of additional charges ✔ 30% ✔ 30% of up to $350/day plus 100% of additional charges ✔ ✔ 30% ✔ ✔ 30% of up to $350/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non-Non- Participating Provider4 CYD2 applies Laboratory services • Laboratory center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location Outpatient Department of a Hospital $20% /visit $20/visit 30% ✔ 40plus 100% of ✔ DME 10% ✔ 40% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies DME 20% ✔ 4030% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 2010% ✔ 4030% ✔ Prosthetic equipment and devices 2010% ✔ 4030% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 2010% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 2010% 10% 10% ✔ ✔✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit periodBenefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 2010% ✔ 4010% ✔ 2010% ✔ 4030% Subject of up to a Benefit maximum of $600/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non- Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-24- hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% ✔ 40% ✔ 20% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Special Food Products Allergy serum billed separately from an office visit 10% $20/visit 10% 10% 10% ✔ 4030% ✔ 30% ✔ 30% of up to $350/day ✔ plus 100% of ✔ additional charges ✔ 10% ✔ ✔ 30% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit $20% ✔ 40/visit 30% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 2010% ✔ 4030% ✔ Partial Hospitalization Program 2010% ✔ 4030% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Psychological Testing 2010% ✔ 4030% ✔ Inpatient services Physician inpatient services $0 ✔ 4010% ✔ 40% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.✔
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered 40% $0 ✔ Primary care office visit 20% ✔ $25/visit 40% ✔ Specialist care office visit 20% ✔ $25/visit 40% ✔ Physician home visit 20% ✔ $25/visit 40% ✔ Physician or surgeon services in an Outpatient Facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician Physician assistants, and therapists. Acupuncture services Up to 20 30 visits per Member, per Calendar Year. Chiropractic services Up to 20 30 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services $25/visit $20% 20% 20% /visit $25/visit $0 $0 $0 $0 20% 20$25/visit 40% ✔ 40% ✔ 40% ✔ Not covered 40% ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal $25/visit 40% ✔ Physician services for pregnancy termination 20% 20✔ 40% ✔✔ ✔✔ Emergency Services services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $15075/visit plus 20% 20% ✔ ✔ $15075/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 20% ✔ $25/visit 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility services 40% Ambulatory Surgery Center 10$0 ✔ 40% ✔ Subject of up to a Benefit maximum ✔ of $3502,000/day 40plus 100% of additional charges ✔ Outpatient Department of a Hospital: surgery 20$0 ✔ 40% ✔ Subject of up to a Benefit maximum ✔ of $3502,000/day plus 100% of additional charges ✔ Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% $0 ✔ 40% Subject of up to a Benefit maximum of $3502,000/day plus 100% of additional charges ✔ Inpatient facility services Hospital services and stay $500/admission plus 20% ✔ $500/admission plus 40% of up to $2,000/day plus 100% of additional charges ✔ Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services $500/admission plus 20% ✔ Not covered • Physician inpatient services 20% 20% 20% ✔ 40% Subject to a Benefit maximum of $600/day ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician services 20% 20% 20% ✔✔✔ Not covered Not covered Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Inpatient facility services $500/admission plus 20% ✔ Not covered Outpatient Facility services $0 ✔ Not covered Physician services 20% ✔ Not covered Laboratory services • Laboratory center 20% ✔ $0 40% ✔ 40% of up to $2,000/day • Outpatient Department of a Hospital 3020% plus 100% of ✔ Subject to a Benefit maximum ✔ of $350/day additional charges X-ray and imaging services • Outpatient radiology center 20% ✔ $0 40% ✔ 40% of up to $2,000/day • Outpatient Department of a Hospital 3020% plus 100% of ✔ Subject to a Benefit maximum ✔ of $350/day additional charges Other outpatient diagnostic testing • Office location 20% ✔ $0 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 20% 20% ✔ 40% ✔ 40% ✔ Subject to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies • Outpatient Department of a Hospital 20% 40% of up to $2,000/day plus 100% of additional charges ✔ Radiological and nuclear imaging services • Outpatient radiology center $0 40% ✔ • Outpatient Department of a Hospital 20% 40% of up to $2,000/day plus 100% of additional charges ✔ Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, and respiratory therapy. Office location Outpatient Department of a Hospital $25/visit $25/visit 40% ✔ plus 100% of ✔ additional charges Office location 20% ✔ 40% ✔ 40% of up to $2,000/day Outpatient Department of a Hospital 20% ✔ plus 100% of ✔ additional charges DME 20% ✔ 40% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 20% ✔ 40% ✔ Prosthetic equipment and devices 20% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 20% 20% 20% ✔ ✔✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit periodBenefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 4020% ✔ 20% ✔ ✔ 40% Subject of up to a Benefit maximum of $6002,000/day plus 100% of additional charges ✔ Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 20% ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training Dialysis services PKU product formulas and Special Food Products Allergy serum billed separately from an office visit 20% $25/visit $0 20% 20% ✔ 40% ✔ 40% ✔ 40% of up to $2,000/day ✔ plus 100% of ✔ additional charges ✔ 20% ✔ ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis Hearing services • Hearing aids and equipment 20% ✔ Subject to a Benefit maximum ✔ Covers 1 pair of $350/day PKU product formulas and special food products hearing aids per member per 36 months. 20% ✔ 20% ✔ Allergy serum billed separately from an office visit 20% ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 20% ✔ $0 40% ✔ Teladoc mental health and substance use disorder (behavioral health health) consultation8 $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% $0 ✔ 40% ✔ Partial Hospitalization Program 20% $0 ✔ 40% Subject of up to a Benefit maximum of $3502,000/day plus 100% of additional charges ✔ Psychological Testing $0 ✔ 40% ✔ Inpatient services Physician inpatient services Hospital services Residential Care $0 $500/admission plus 20% $500/admission plus 20% ✔ 40% ✔ Physician inpatient services ✔ $0 ✔ 500/admission plus 40% ✔ 40% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $2502,000/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices plus 100% of additional charges ✔ ✔ $0 Tier 1 Drugs $30500/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30admission plus 40% of up to $7502,000/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% day plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25100% of purchase price additional charges ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit $20% ✔ /visit 40% ✔ Specialist care office visit $20% ✔ /visit 40% ✔ Physician home visit $20% ✔ /visit 40% ✔ Physician or surgeon services in an Outpatient Facility outpatient facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 30 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, ; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services $20% /visit $20% /visit $20% /visit $0 $0 $0 $0 20% $20/visit 40% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 20% 20% ✔✔ ✔✔ Emergency Services services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 20% ✔ ✔ $150/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services $20% ✔ /visit 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility facility services 40% Ambulatory Surgery Center 1020% ✔ Subject 40% of up to a Benefit maximum ✔ of $350/day 40plus 100% of additional charges ✔ Outpatient Department of a Hospital: surgery 20% ✔ Subject 40% of up to a Benefit maximum ✔ of $350/day plus 100% of additional charges ✔ Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 40% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 20% 20% 20% ✔ 40% Subject of up to a Benefit maximum of $6001,000/day plus 100% of additional charges ✔ ✔ Not covered ✔ Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility outpatient facility services and outpatient Outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician facility services 20% 20% 20% ✔✔✔ Not covered Not covered Physician services When using a Participating Provider3 20% CYD2 applies ✔ When using a Non-Participating Provider4 Not covered CYD2 applies Laboratory services Includes diagnostic Papanicolaou (Pap) test. • Laboratory center 20% ✔ 40% ✔ • Outpatient Department of a Hospital 20% ✔ 40% of up to $350/day plus 100% of additional charges ✔ X-ray and imaging services Includes diagnostic mammography. • Outpatient radiology center 20% ✔ 40% ✔ • Outpatient Department of a Hospital 20% ✔ 40% of up to $350/day plus 100% of additional charges ✔ 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 motion tests, EEG, and EMG. • Office location 20% ✔ 40% ✔ • Outpatient Department of a Hospital 20% ✔ 40% of up to $350/day plus 100% of additional charges ✔ Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ • Outpatient Department of a Hospital 20% ✔ 40% of up to $350/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Laboratory services • Laboratory center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Other outpatient diagnostic testing • Office location 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 20% 20% ✔ 40% ✔ ✔ 40% ✔ Subject of up to a Benefit maximum ✔ of $350/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies plus 100% of additional charges ✔ DME 20% ✔ 40% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 20% ✔ 40% ✔ Prosthetic equipment and devices 20% ✔ 40% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse Hemophilia home infusion services Includes blood factor products. 20% ✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit periodBenefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 40% ✔ 20% ✔ 40% Subject of up to a Benefit maximum of $6001,000/day plus 100% of additional charges ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training 20% ✔ 40% ✔ 20% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350/day PKU product formulas and special food products 20% ✔ 20% ✔ Special Food Products Allergy serum billed separately from an office visit 20% $20/visit 20% 20% 20% ✔ 40% ✔ 40% ✔ 40% of up to $350/day ✔ plus 100% of ✔ additional charges ✔ 20% ✔ ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit $20% ✔ /visit 40% ✔ Teladoc behavioral health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% ✔ 40% ✔ Partial Hospitalization Program 20% ✔ 40% Subject of up to a Benefit maximum of $350/day plus 100% of additional charges ✔ Psychological Testing 20% ✔ 40% ✔ Inpatient services Physician inpatient services $0 ✔ 4020% ✔ 40% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.✔
Appears in 1 contract
Samples: Group Health Service Contract
No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit 20% ✔ $15/visit 40% ✔ Specialist care office visit 20% ✔ $15/visit 40% ✔ Physician home visit 20% ✔ $15/visit 40% ✔ Physician or surgeon services in an Outpatient Facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, therapists, and therapistspodiatrists. Acupuncture services Up to 20 12 visits per Member, per Calendar Year. Chiropractic services Up to 20 30 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 20% 20% 20% Medical nutrition therapy, not related to diabetes $15/visit $15/visit $15/visit $0 $0 $0 $0 $0 20% 2040% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal Physician Abortion and abortion-related services for pregnancy termination 20% 20$0 ✔ 40% ✔$0 ✔ ✔✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Emergency Services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 20% ✔ ✔ $150/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 20% ✔ $15/visit 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility services 40% Ambulatory Surgery Center 1020% ✔ Subject to a Benefit maximum ✔ of $350600/day 40% Outpatient Department of a Hospital: surgery 20% ✔ Subject to a Benefit maximum ✔ of $350600/day Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 40% Subject to a Benefit maximum of $350600/day ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services • Physician inpatient services 20% 20% 20% ✔ 40% Subject to a Benefit maximum of $6001,500/day ✔ ✔ Not covered ✔ Not covered When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and outpatient Physician services payments apply. Inpatient facility services Outpatient Facility services Physician services 20% 20% 20% ✔✔✔ Not covered Not covered Not covered Laboratory and pathology services • Laboratory center $15/visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 20% ✔ Subject to a Benefit maximum ✔ of $600/day Basic imaging services • Outpatient radiology center $15/visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 20% ✔ Subject to a Benefit maximum ✔ of $600/day Other outpatient non-invasive diagnostic testing • Office location $15/visit ✔ 40% ✔ 40% • Outpatient Department of a Hospital 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Laboratory services • Laboratory center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day X-ray and Advanced imaging services Includes diagnostic radiological and nuclear imaging such as CT scans, MRIs, MRAs, and PET scans. • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 3020% ✔ 40% Subject to a Benefit maximum ✔ of $350600/day Other outpatient diagnostic testing • Office location 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital 30% ✔ Subject to a Benefit maximum ✔ of $350/day Radiological and nuclear imaging services • Outpatient radiology center 20% ✔ 40% ✔ 40% • Outpatient Department of a Hospital $100/visit plus 20% ✔ Subject to a Benefit maximum ✔ of $350/day Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location Outpatient Department of a Hospital 20% 20% $15/visit $15/visit ✔ 40% ✔ 40% ✔ Subject to a Benefit maximum ✔ of $350600/day When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies DME 20% ✔ 40% ✔ Breast pump $0 Not covered Glucose monitor 20% 40% ✔ Peak Flow Meter 20% 40% ✔ Orthotic equipment and devices 20% ✔ 40% ✔ Prosthetic equipment and devices 20% ✔ 40% ✔ Home health care services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. 20% ✔ Not covered Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and drugs, medical supplies. Home , and visits by an infusion nurse a nurse. Hemophilia home infusion services Includes blood factor products. 20% $45/visit $45/visit ✔ ✔ Not covered 20% ✔ Not covered 20% ✔ Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF Hospital-based SNF 20% ✔ 40% ✔ Hospital-based SNF When using a Participating Provider3 20% CYD2 applies ✔ When using a Non-Participating Provider4 40% Subject to a Benefit maximum of $6001,500/day CYD2 applies ✔ Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 ✔ Not covered Other services and supplies Diabetes care services • Devices, equipment, and supplies • Self-management training • Medical nutrition therapy Dialysis services PKU product formulas and special food products Allergy serum billed separately from an office visit 20% $15/visit $15/visit 20% 20% 20% ✔ 40% ✔ 2040% ✔ 40% ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies 40% Dialysis services 20% ✔ Subject to a Benefit maximum ✔ of $350600/day PKU product formulas and special food products 20% ✔ 20% ✔ Allergy serum billed separately from an office visit 20% ✔ 40% ✔ Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non- Participating Provider4 CYD2 applies Office visit, including Physician office visit 20% ✔ $15/visit 40% ✔ Teladoc behavioral mental health $0 ✔ Not covered Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non- institutional facility setting, and office-based opioid treatment 20% ✔ 40% ✔ Partial Hospitalization Program 20% ✔ 40% Subject to a Benefit maximum of $350600/day ✔ Psychological Testing 20% ✔ 40% ✔ Inpatient services Physician inpatient services $0 ✔ 4020% ✔ 40% Hospital services 20% ✔ Subject to a Benefit maximum ✔ of $600/day 40% Residential Care 20% ✔ Subject to a Benefit maximum ✔ of $600/day When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $10/prescription Tier 2 Drugs $25/prescription Tier 3 Drugs $40/prescription Tier 4 Drugs 30% up to $250/prescription Retail pharmacy prescription Drugs Per prescription, up to a 90-day supply from a 90-day retail pharmacy. Contraceptive Drugs and devices $0 Tier 1 Drugs $30/prescription Tier 2 Drugs $75/prescription Tier 3 Drugs $120/prescription Tier 4 Drugs 30% up to $750/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment ✔ 25% plus $10/prescription ✔ ✔ 25% plus $25/prescription ✔ ✔ 25% plus $40/prescription ✔ ✔ 30% up to $250/prescription plus 25% of purchase price ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices $0 Tier 1 Drugs $20/prescription Tier 2 Drugs $50/prescription Tier 3 Drugs $80/prescription Tier 4 Drugs 30% up to$500/prescription Not covered ✔ Not covered ✔ Not covered ✔ Not covered ✔ Not covered The following are some frequently-utilized Benefits that require prior authorization: • Radiological and nuclear imaging services • Hospice program services • Outpatient mental health services, except office visits • Inpatient facility services • Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization.✔
Appears in 1 contract
Samples: Group Health Service Contract
