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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Coverage Period: Beginning On or After 1/1/2025

Silver 87 PPO Coverage for: Individual + Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit bsca.com/policies/MK002185_EOC.pdf
or call 1-855-836-9705. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1-866-444-3272 to request a copy.
Important Questions Answers Why This Matters:
$0 per individual / $0 per family for Generally, you must pay all of the costs from providers up to the deductible amount before
What is the overall participating providers; $7,000 per this plan begins to pay. If you have other family members on the plan each family member
deductible? individual / $14,000 per family for non- must meet their own individual deductible until the total amount of deductible expenses paid
participating providers. by all family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible
Are there services Yes. Preventive care and services
amount. But a copayment or coinsurance may apply. For example, this plan covers certain
covered before you meet listed in your complete terms of
preventive services without cost-sharing and before you meet your deductible. See a list of
your deductible? coverage.
covered preventive services at healthcare.gov/coverage/preventive-care-benefits.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
$3,000 per individual / $6,000 per
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
What is the out-of-pocket family for participating providers;
other family members in this plan, they have to meet their own out-of-pocket limits until the
limit for this plan? $25,000 per individual / $50,000 per
overall family out-of-pocket limit has been met.
family for non-participating providers.
Copayments for certain services,
What is not included in
premiums, balance-billing charges, and Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
health care this plan doesn’t cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
Yes. See blueshieldca.com/fad or call network. You will pay the most if you use an out-of-network provider, and you might receive
Will you pay less if you
1-855-836-9705 for a list of network a bill from a provider for the difference between the provider’s charge and what your plan
use a network provider?
providers. pays (balance billing). Be aware, your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to
No. You can see the specialist you choose without a referral.
see a specialist?
Blue Shield of California is an independent member of the Blue Shield Association.

Covered California is a registered trademark of the State of California.
1 of 8
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an
$15/visit 50% coinsurance
injury or illness ----------------------None-----------------------
If you visit a health Specialist visit $25/visit 50% coinsurance
care provider's office You may have to pay for services that
or clinic Preventive care/screening aren’t preventive. Ask your provider if
No Charge Not Covered
/immunization the services needed are preventive.
Then check what your plan will pay for.
Lab & Path: 50%
coinsurance
Lab & Path: $20/visit
X-Ray & Imaging: 50%
Diagnostic test (x-ray, blood X-Ray & Imaging: $40/visit The services listed are at a
coinsurance
work) Other Diagnostic Examination: freestanding location.
Other Diagnostic
$40/visit
Examination: 50%
If you have a test coinsurance
Outpatient Radiology Center:
50% coinsurance
Outpatient Radiology Center: Preauthorization is required. Failure to
Outpatient Hospital: 50%
Imaging (CT/PET scans, MRIs) $100/visit obtain preauthorization may result in
coinsurance subject to a
Outpatient Hospital: $100/visit non-payment of benefits.
benefit maximum of
$500/day
If you need drugs to Retail: $5/prescription Retail: Not Covered Preauthorization is required for select
Tier 1
treat your illness or Mail Service: $15/prescription Mail Service: Not Covered drugs. Failure to obtain
condition Retail: $25/prescription Retail: Not Covered preauthorization may result in non-
Tier 2
More information about Mail Service: $75/prescription Mail Service: Not Covered payment of benefits.
prescription drug Retail: $45/prescription Retail: Covers up to a 30-day supply;
Retail: Not Covered Mail Service: Covers up to a 90-day
coverage is available at Tier 3 Mail Service:
Mail Service: Not Covered
blueshieldca.com/ $135/prescription supply.

* For more information about limitations and exceptions, see the plan or Covered California is a registered trademark of the State of California.
policy document at bsca.com/policies/MK002185_EOC.pdf. 2 of 8
What You Will Pay
formulary Preauthorization is required. Failure to
obtain preauthorization may result in
Retail and Network Specialty non-payment of benefits.
Pharmacies: 15% coinsurance Retail and Network Specialty
up to $150/prescription Retail: Not Covered Pharmacies: Covers up to a 30-day
Tier 4
Mail Service: 15% Mail Service: Not Covered supply; Specialty drugs must be
coinsurance up to obtained at a Network Specialty
$450/prescription Pharmacy.
Mail Service: Covers up to a 90-day
supply.
Ambulatory Surgery Center:
50% coinsurance subject to a
Ambulatory Surgery Center: benefit maximum of
Facility fee (e.g., ambulatory 20% coinsurance $300/day
If you have outpatient
surgery center) Outpatient Hospital: 20% Outpatient Hospital: 50% ----------------------None-----------------------
surgery coinsurance coinsurance subject to a
benefit maximum of
$500/day
Physician/surgeon fees 20% coinsurance 50% coinsurance
Facility Fee: $150/visit;
Facility Fee: $150/visit deductible does not apply
Emergency room care ----------------------None-----------------------
Physician Fee: No Charge Physician Fee: No Charge;
If you need immediate deductible does not apply
medical attention
Emergency medical $75/transport; deductible This payment is for emergency or
$75/transport
transportation does not apply authorized transport.
Urgent care $15/visit 50% coinsurance ----------------------None-----------------------
50% coinsurance subject to a Preauthorization is required. Failure to
If you have a hospital Facility fee (e.g., hospital room) 20% coinsurance benefit maximum of obtain preauthorization may result in
stay $500/day non-payment of benefits.
Physician/surgeon fees 20% coinsurance 50% coinsurance ----------------------None-----------------------

What You Will Pay
Office Visit: 50% coinsurance
Office Visit: $15/visit Other Outpatient Services:
Other Outpatient Services: No 50% coinsurance Preauthorization is required except for
Charge Partial Hospitalization: 50% office visits and office-based opioid
Outpatient services Partial Hospitalization: No coinsurance subject to a treatment. Failure to obtain
Charge benefit maximum of preauthorization may result in non-
Psychological Testing: No $500/day payment of benefits.
Charge Psychological Testing: 50%
If you need mental
coinsurance
health, behavioral
Physician Inpatient Services:
health, or substance
50% coinsurance
abuse services
Physician Inpatient Services: Hospital Services: 50%
20% coinsurance coinsurance subject to a
Preauthorization is required. Failure to
Hospital Services: 20% benefit maximum of
Inpatient services obtain preauthorization may result in
coinsurance $500/day
non-payment of benefits.
Residential Care: 20% Residential Care: 50%
coinsurance coinsurance subject to a
benefit maximum of
$500/day
Office visits No Charge 50% coinsurance
Childbirth/delivery professional
20% coinsurance 50% coinsurance
services
If you are pregnant ----------------------None-----------------------
50% coinsurance subject to a
Childbirth/delivery facility
20% coinsurance benefit maximum of
services
$500/day
Home health care $15/visit Not Covered non-payment of benefits. Coverage
If you need help limited to 100 visits per member per
recovering or have Calendar Year.
other special health Office Visit: 50% coinsurance
needs Outpatient Hospital: 50%
Office Visit: $15/visit
Rehabilitation services coinsurance subject to a ----------------------None-----------------------
Outpatient Hospital: $15/visit
benefit maximum of
$500/day

What You Will Pay
Office Visit: 50% coinsurance
Outpatient Hospital: 50%
Office Visit: $15/visit
Habilitation services coinsurance subject to a
Outpatient Hospital: $15/visit
benefit maximum of
$500/day
Freestanding SNF: 50%
Freestanding SNF: 20% coinsurance
coinsurance Hospital-based SNF: 50%
Skilled nursing care non-payment of benefits. Coverage
Hospital-based SNF: 20% coinsurance subject to a
limited to 100 days per member per
coinsurance benefit maximum of
benefit period.
$500/day
Durable medical equipment 15% coinsurance 50% coinsurance obtain preauthorization may result in
Preauthorization is required except for
pre-hospice consultation. Failure to
Hospice services No Charge Not Covered
All charges above $30; Coverage limited to one exam per
Children's eye exam No Charge
deductible does not apply member per Calendar Year.
Coverage is limited to one eyeglass
frame and eyeglass lenses or contact
All charges above $25;
If your child needs Children's glasses No Charge lenses instead of eyeglasses, up to the
deductible does not apply
dental or eye care benefit per Calendar Year. The cost
listed is for Single Vision.
Coverage for prophylaxis services
10% coinsurance; deductible
Children's dental check-up No Charge (cleaning) is limited to once in a six
does not apply
month period.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Non-emergency care when
• Chiropractic Care • Hearing Aids • Routine foot care
traveling outside the U.S.
• Cosmetic surgery • Infertility Treatment • Private-duty nursing • Weight loss programs
• Dental care (Adult) • Long-term care • Routine eye care (Adult)

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
• Acupuncture • Bariatric surgery • Services related to Abortion
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies
is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or cciio.cms.gov. Other coverage
options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the
Marketplace, visit HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice or assistance, contact:
Blue Shield Customer Service at 1-855-836-9705. Additionally, you can contact the California Department of Managed Health Care Help at 1-888-466-2219 or visit
[email protected] or visit http://www.healthhelp.ca.gov.
Does this plan provide Minimum Essential Coverage? Yes

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Not Applicable
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of participating pre-natal care and a (a year of routine participating care of a well- (participating emergency room visit and follow up
hospital delivery) controlled condition) care)
◼ The plan’s overall deductible $0 ◼ The plan’s overall deductible $0 ◼ The plan’s overall deductible $0
◼ Specialist copayment $25 ◼ Specialist copayment $25 ◼ Specialist copayment $25
◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20%
◼ Other copayment $20 ◼ Other copayment $20 ◼ Other copayment $40
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $400 Copayments $700 Copayments $300
Coinsurance $2,200 Coinsurance $100 Coinsurance $100
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $2,700 The total Joe would pay is $800 The total Mia would pay is $400

Covered California is a registered trademark of the State of California.
The plan would be responsible for the other costs of these EXAMPLE covered services. 8 of 8
Evidence of Coverage and
Health Service Agreement
Blue Shield of California is an independent member of the Blue Shield Association

Individual and Family Plan
Blue Shield Silver 87 PPO
Provider Network: Exclusive
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at [Variable
language. Applicable to: Channel: On Exchange] [(855) 836-9705]] [Variable language. Applicable to:
Channel: Off Exchange or Mirrored] [(888) 256-3650]].
2
Table of contents
Table of contents .......................................................................................................................................2

Summary of Benefits ..................................................................................................................................4
Introduction ..............................................................................................................................................17
About this Agreement ..........................................................................................................................17
About this plan ......................................................................................................................................18
How to contact Customer Service .....................................................................................................18
This Agreement is a contract between you and Blue Shield ..............................................................20
Your bill of rights.......................................................................................................................................21
Your responsibilities .................................................................................................................................23
How to access care ................................................................................................................................24
Health care professionals and facilities ..............................................................................................24
Benefit Administrators ...........................................................................................................................25
Your Primary Care Physician ................................................................................................................25
ID cards ..................................................................................................................................................26
Canceling appointments.....................................................................................................................26
Continuity of care .................................................................................................................................26
Second medical opinion......................................................................................................................27
Care outside of California....................................................................................................................28
Emergency Services..............................................................................................................................28
If you cannot find a Participating Provider ........................................................................................29
Other ways to access care..................................................................................................................29
Timely access to care...........................................................................................................................31
Health advice and education ............................................................................................................32
Medical Management Programs...........................................................................................................34
Prior authorization .................................................................................................................................34
While you are in the Hospital (inpatient utilization review) ..............................................................36
After you leave the Hospital (discharge planning)...........................................................................37
Using your Benefits effectively (care management)........................................................................37
Your payment information......................................................................................................................38
Paying for coverage.............................................................................................................................38
Paying for Covered Services................................................................................................................39
Claims .....................................................................................................................................................43
Your coverage .........................................................................................................................................45
Eligibility for this plan .............................................................................................................................45
Enrollment and effective dates of coverage ....................................................................................46
Terms of coverage ................................................................................................................................48
When coverage ends...........................................................................................................................48
Your Benefits.............................................................................................................................................53
Acupuncture services...........................................................................................................................53
Allergy testing and immunotherapy Benefits.....................................................................................53
Ambulance services .............................................................................................................................54
Bariatric surgery Benefits ......................................................................................................................54
Clinical trials for treatment of cancer or life-threatening diseases or conditions Benefits ...........55
Diabetes care services .........................................................................................................................56
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at (855) 836-
9705.
Table of contents 3
Diagnostic X-ray, imaging, pathology, laboratory, and other testing services .............................57
Dialysis Benefits ......................................................................................................................................58
Durable medical equipment...............................................................................................................58
Emergency Benefits ..............................................................................................................................60
Family planning Benefits.......................................................................................................................61
Fertility preservation services................................................................................................................61
Home health services ...........................................................................................................................61
Hospice program services....................................................................................................................63
Hospital services ....................................................................................................................................64
Medical treatment of the teeth, gums, jaw joints, and jaw bones.................................................65
Mental Health and Substance Use Disorder Benefits........................................................................66
Pediatric dental Benefits ......................................................................................................................68
Pediatric vision Benefits ........................................................................................................................69
Physician and other professional services..........................................................................................71
PKU formulas and special food products...........................................................................................71
Podiatric services ..................................................................................................................................72
Pregnancy and maternity care ..........................................................................................................72
Prescription Drug Benefits.....................................................................................................................72
Preventive Health Services...................................................................................................................79
Reconstructive Surgery Benefits ..........................................................................................................80
Rehabilitative and habilitative services..............................................................................................80
Skilled Nursing Facility (SNF) services ...................................................................................................81
Transplant services ................................................................................................................................82
Urgent care services .............................................................................................................................82
Exclusions and limitations .......................................................................................................................84
Grievance process ..................................................................................................................................95
Submitting a grievance........................................................................................................................95
California Department of Managed Health Care review ...............................................................96
Independent medical review..............................................................................................................97
Other important information about your plan ......................................................................................98
Your coverage, continued ..................................................................................................................98
Special enrollment period....................................................................................................................98
Out-of-area services ...........................................................................................................................101
Limitation for duplicate coverage ....................................................................................................103
Exception for other coverage ...........................................................................................................104
Reductions – third-party liability.........................................................................................................104
General provisions...............................................................................................................................106
Definitions ...............................................................................................................................................110
Notices about your plan .......................................................................................................................127
Pediatric dental Benefits table .............................................................................................................132
9705.
Summary of Benefits Individual and Family Plan
PPO Plan
Silver 87 PPO
This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It
is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully
for details.
Medical Provider Network: Exclusive PPO Network

This Plan uses a specific network of Health Care Providers, called the Exclusive PPO provider network. Providers in this
network are called Participating Providers. You pay less for Covered Services when you use a Participating Provider
than when you use a Non-Participating Provider. You can find Participating Providers in this network at
blueshieldca.com.
Pharmacy Network: Rx Ultra
Drug Formulary: Standard Formulary
Calendar Year Deductibles (CYD)2

A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for
Covered Services under the Plan.
When using a When using a Non-
Participating Participating
Provider3 Provider4
Blue Shield of California is an independent member of the Blue Shield Association

Calendar Year medical Deductible Individual coverage $0 $7,000
Family coverage $0: individual $7,000: individual
$0: Family $14,000: Family
Calendar Year pharmacy Deductible Individual coverage $0 Not covered
Family coverage $0: individual Not covered
$0: Family
Calendar Year Out-of-Pocket Maximum5

An Out-of-Pocket Maximum is the most a Member will pay for Covered No Annual or Lifetime Dollar
Services each Calendar Year. Any exceptions are listed in the Notes section at
Limit
the end of this Summary of Benefits.
When using a When using a Non- Under this Plan there is no
Participating Provider3 Participating Provider4 annual or lifetime dollar limit on
Individual coverage $3,000 $25,000 the amount Blue Shield will pay
for Covered Services.
Family coverage $3,000: individual $25,000: individual
$6,000: Family $50,000: Family
A46208 (01/25) 4
Benefits6 Your payment
When using a CYD2 When using a CYD2
Participating applies Non-Participating applies
Provider3 Provider4
Preventive Health Services7

Preventive Health Services $0 Not covered
California Prenatal Screening Program $0 $0
Physician services
Primary care office visit $15/visit 50% 
Specialist care office visit $25/visit 50% 
Physician home visit $15/visit 50% 
Physician or surgeon services in an Outpatient
20% 50% 
Facility
Physician or surgeon services in an inpatient facility 20% 50% 
Other professional services

Other practitioner office visit $15/visit 50% 
Includes nurse practitioners, physician assistants,
therapists, and podiatrists.
Acupuncture services $15/visit 50% 
Chiropractic services Not covered Not covered
Teladoc consultation $0 Not covered
Family planning
• Counseling, consulting, and education $0 Not covered
• Injectable contraceptive, diaphragm fitting,
intrauterine device (IUD), implantable $0 Not covered
contraceptive, and related procedure.
• Tubal ligation $0 Not covered
• Vasectomy $0 Not covered
• Infertility services Not covered Not covered
Pregnancy and maternity care

Physician office visits: prenatal and initial postnatal $0 50% 
$0 $0
Abortion and abortion-related services
Emergency Services
Emergency room services $150/visit $150/visit
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 $0 $0
5
Provider3 Provider4
Urgent care center services $15/visit 50% 
Ambulance services $75/transport $75/transport

This payment is for emergency or authorized transport.
Outpatient Facility services

50%
Subject to a
Ambulatory Surgery Center 20% 
Benefit maximum
of $300/day
50%
Subject to a
Outpatient Department of a Hospital: surgery 20% 
Benefit maximum
of $500/day
50%
Outpatient Department of a Hospital: treatment of
Subject to a
illness or injury, radiation therapy, chemotherapy, 20% 
Benefit maximum
and necessary supplies
of $500/day
Inpatient facility services

50%
Subject to a
Hospital services and stay 20% 
Benefit maximum
of $500/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 20% Not covered
• Physician inpatient services 20% 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 20% Not covered
Outpatient Facility services 20% Not covered
Physician services 20% Not covered
6
Provider3 Provider4
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. For the payments
for Covered Services that are considered Preventive
Health Services, see Preventive Health Services.
Laboratory and pathology services
Includes diagnostic Papanicolaou (Pap) test.
• Laboratory center $20/visit 50% 
50%
Subject to a
• Outpatient Department of a Hospital $20/visit 
Benefit maximum
of $500/day
Basic imaging services
Includes plain film X-rays, ultrasounds, and
diagnostic mammography.
• Outpatient radiology center $40/visit 50% 
50%
Subject to a
Benefit maximum
of $500/day
Other outpatient non-invasive diagnostic testing
Testing to diagnose illness or injury such as
vestibular function tests, EKG, cardiac monitoring,
non-invasive vascular studies, sleep medicine
testing, muscle and range of motion tests, EEG,
and EMG.
• Office location $40/visit 50% 
50%
Subject to a
Benefit maximum
of $500/day
Advanced imaging services
Includes diagnostic radiological and nuclear
imaging such as CT scans, MRIs, MRAs, and PET
scans.
• Outpatient radiology center $100/visit 50% 
50%
Subject to a
Benefit maximum
of $500/day
7
Provider3 Provider4
Rehabilitative and habilitative services

Includes physical therapy, occupational therapy,
respiratory therapy, and speech therapy services.
There is no visit limit for rehabilitative or habilitative
services.
Office location $15/visit 50% 
50%
Subject to a
Outpatient Department of a Hospital $15/visit 
Benefit maximum
of $500/day
Durable medical equipment (DME)

DME 15% 50% 
Breast pump $0 Not covered
Orthotic equipment and devices 15% 50% 
Prosthetic equipment and devices 15% 50% 
Home health care services $15/visit Not covered

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.
Home infusion and home injectable therapy services

Home infusion agency services $0 Not covered
Includes home infusion drugs, medical supplies,
and visits by a nurse.
Hemophilia home infusion services $0 Not covered
Includes blood factor products.
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 20% 50% 
50%
Subject to a
Hospital-based SNF 20% 
Benefit maximum
of $500/day
8
Provider3 Provider4
Hospice program services $0 Not covered

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.
Other services and supplies

Diabetes care services
• Devices, equipment, and supplies 15% 50% 
• Self-management training $0 50% 
• Medical nutrition therapy $0 50% 
50%
Subject to a
Dialysis services 20% 
Benefit maximum
of $300/day
PKU product formulas and special food products 20% 20%
Allergy serum billed separately from an office visit 20% 50% 
Mental Health and Substance Use Disorder Benefits Your payment

Mental health and substance use disorder Benefits are
MHSA applies MHSA Non- applies
provided through Blue Shield's Mental Health Service
Administrator (MHSA).
Provider3 Provider4
Outpatient services
Office visit, including Physician office visit $15/visit 50% 
Teladoc 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 $0 50% 
autism in an office setting, home, or other non-
institutional facility setting, and office-based opioid
treatment
50%
Subject to a
Partial Hospitalization Program $0 
Benefit maximum
of $500/day
Psychological Testing $0 50% 
Inpatient services
Physician inpatient services 20% 50% 
9
Mental Health and Substance Use Disorder Benefits Your payment
Mental health and substance use disorder Benefits are
MHSA applies MHSA Non- applies
provided through Blue Shield's Mental Health Service
Administrator (MHSA).
Provider3 Provider4
50%
Hospital services 20% Subject to a 
Benefit maximum
of $500/day
50%
Subject to a
Residential care 20% 
Benefit maximum
of $500/day
Prescription Drug Benefits8,9 Your payment

Pharmacy3 Pharmacy4
Retail pharmacy prescription Drugs

Per prescription, up to a 30-day supply.
Contraceptive Drugs and devices $0 Not covered
Tier 1 Drugs $5/prescription Not covered
Not covered
Tier 2 Drugs $25/prescription
Not covered
15% up to Not covered

Tier 4 Drugs
$150/prescription
Mail service pharmacy prescription Drugs

Per prescription, for a 90-day supply.
Not covered
Contraceptive Drugs and devices $0
Not covered
Not covered
Not covered
15% up to Not covered

Tier 4 Drugs
$450/prescription
10
Pediatric Benefits Your payment
Pediatric Benefits are available through the end of the
month in which the Member turns 19.
Dentist3 Dentist4
Pediatric dental10
Diagnostic and preventive services
• Oral exam $0 10%
• Preventive – cleaning $0 10%
• Preventive – x-ray $0 10%
• Sealants per tooth $0 10%
• Topical fluoride application $0 10%
• Space maintainers - fixed $0 10%
Basic services
• Restorative procedures 20% 30%
• Periodontal maintenance 20% 30%
• Adjunctive general services 20% 30%
Major services
• Oral surgery 50% 50%
• Endodontics 50% 50%
• Periodontics (other than maintenance) 50% 50%
• Crowns and casts 50% 50%
• Prosthodontics 50% 50%
Orthodontics (Medically Necessary) 50% 50%

Provider3 Provider4
Pediatric vision11
Comprehensive eye examination
One exam per Calendar Year.
All charges
• Ophthalmologic visit $0
above $30
All charges
• Optometric visit $0
above $30
Contact lens fitting and evaluation
When you choose contact lenses instead of
eyeglasses, one per Member every 12 months by
a Participating Provider if administered at the
same time as the comprehensive exam. There is a
maximum of two follow up visits.
• Standard lenses $0 Not covered
All charges
• Non-standard lenses Not covered
above $60
11
Provider3 Provider4
Eyewear/materials
One eyeglass frame and eyeglass lenses, or
contact lenses instead of eyeglasses, up to the
Benefit per Calendar Year. Any exceptions are
noted below.
• Contact lenses
Non-elective (Medically Necessary) - hard or All charges
$0
soft above $225
Up to two pairs per eye per Calendar Year.
Elective (cosmetic/convenience)
All charges
Standard and non-standard, hard $0
above $75
Up to a 3 month supply for each eye per
Calendar Year based on lenses
selected.
All charges
Standard and non-standard, soft $0
above $75
Up to a 6 month supply for each eye per
Calendar Year based on lenses
selected.
• Eyeglass frames
All charges
Collection frames $0
above $40
All charges All charges
Non-collection frames
above $150 above $40
• Eyeglass lenses
Lenses include choice of glass or plastic
lenses, all lens powers (single vision, bifocal,
trifocal, lenticular), fashion or gradient tint,
scratch coating, oversized, and glass-grey
#3 prescription sunglasses.
All charges
Single vision $0
above $25
All charges
Lined bifocal $0
above $35
All charges
Lined trifocal $0
above $45
All charges
Lenticular $0
above $45
Optional eyeglass lenses and treatments
• Ultraviolet protective coating (standard only) $0 Not covered
• Polycarbonate lenses $0 Not covered
• Standard progressive lenses $0 Not covered
• Premium progressive lenses $95 Not covered
• Anti-reflective lens coating (standard only) $35 Not covered
12
Provider3 Provider4
• Photochromic - glass lenses $25 Not covered
• Photochromic - plastic lenses $0 Not covered
• High index lenses $30 Not covered
• Polarized lenses $45 Not covered
Low vision testing and equipment
• Comprehensive low vision exam $0 Not covered
Once every 5 Calendar Years.
• Low vision devices $0 Not covered
One aid per Calendar Year.
Prior Authorization
The following are some frequently-utilized Benefits that require prior authorization:
• Advanced imaging services • Hospice program services
• Outpatient mental health services, except • Some prescription Drugs (see
office visits and office-based opioid blueshieldca.com/pharmacy)
treatment
• Inpatient facility services
• Pediatric vision non-elective contact lenses
and low vision testing and equipment
Please review the Evidence of Coverage for more about Benefits that require prior authorization.
Notes
1 Evidence of Coverage (EOC):

The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this
Plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy
of the EOC at any time.
Capitalized terms are defined in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of
Benefits.
2 Calendar Year Deductible (CYD):

Calendar Year Deductible explained. A Calendar Year Deductible is the amount you pay each Calendar Year before
Blue Shield pays for Covered Services under the Plan.
If this Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a
check mark () in the Benefits chart above.
Family coverage has an individual Deductible within the Family Deductible. This means that the Deductible will be met
for an individual with Family coverage who meets the individual Deductible prior to the Family meeting the Family
Deductible within a Calendar Year. Any amount you have paid toward the individual Deductible will be applied to
both the individual Deductible and the Family Deductible. Once the individual Deductible or Family Deductible is
reached, cost sharing applies until the Out-of-Pocket Maximum is reached.
3 Using Participating Providers:
13
Participating Providers have a contract to provide health care services to Members. When you receive Covered
Services from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar
Year Deductible has been met.
Teladoc. Teladoc mental health and substance use disorder consultations are provided through Teladoc. These
services are not administered by Blue Shield's Mental Health Service Administrator (MHSA).
"Allowable Amount" is defined in the EOC. In addition:
• Coinsurance is calculated from the Allowable Amount.
4 Using Non-Participating Providers:

Non-Participating Providers do not have a contract to provide health care services to Members. When you receive
Covered Services from a Non-Participating Provider, you are responsible for:
• the Copayment or Coinsurance (once any Calendar Year Deductible has been met), and
• any charges above the Allowable Amount.
“Allowable Amount” is defined in the EOC. In addition:

• Coinsurance is calculated from the Allowable Amount, which is subject to any stated Benefit maximum.
• Charges above the Allowable Amount do not count towards the Out-of-Pocket Maximum, and are your
responsibility for payment to the provider. This out-of-pocket expense can be significant.
5 Calendar Year Out-of-Pocket Maximum (OOPM):

Calendar Year Out-of-Pocket Maximum explained. The Out-of-Pocket Maximum is the most you are required to pay
for Covered Services in a Calendar Year. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of
the Allowable Amount for Covered Services for the rest of the Calendar Year.
Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges for services that are not
covered and charges above the Allowable Amount.
Any Deductibles count towards the OOPM. Any amounts you pay that count towards the medical Calendar Year
Deductible also count towards the Calendar Year Out-of-Pocket Maximum.
This Plan has a separate Participating Provider OOPM and Non-Participating Provider OOPM.
Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for an
individual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM within
a Calendar Year. Any amount you have paid toward the individual OOPM will be applied to both the individual and
the Family OOPM, except for Out-of-Network pediatric dental services. Cost sharing payments for pediatric dental
services made by each individual child for Out-of-Network Covered Services do not accumulate to the Family Out-of-
Pocket Maximum.
6 Separate Member Payments When Multiple Covered Services are Received:

Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance)
for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example,
you may owe an office visit payment in addition to an allergy serum payment when you visit the doctor for an allergy
shot.
7 Preventive Health Services:

If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for
the visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit,
you may have a Copayment or Coinsurance for the visit.
14
8 Outpatient Prescription Drug Coverage:
Medicare Part D-creditable coverage-
This Plan’s prescription drug coverage is on average equivalent to or better than the standard benefit set by the
federal government for Medicare Part D (also called creditable coverage). Because this plan’s prescription drug
coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you
should be aware that if you do not enroll in Medicare Part D within 63 days following termination of this coverage, you
could be subject to Medicare Part D premium penalties.
9 Outpatient Prescription Drug Coverage:

Brand Drug coverage when a Generic or Biosimilar Drug is available. If you, the Physician, or Health Care Provider,
select a Brand Drug when a Generic Drug equivalent or Biosimilar Drug is available, you are responsible for the
difference between the cost to Blue Shield for the Brand Drug and its Generic Drug equivalent or Biosimilar Drug plus
the applicable tier Copayment or Coinsurance of the Brand Drug. This difference in cost will not count towards any
Calendar Year pharmacy Deductible, medical Deductible, or the Calendar Year Out-of-Pocket Maximum.
See the Obtaining outpatient prescription Drugs at a Participating Pharmacy section of the EOC for more information
about how a brand contraceptive may be covered without a Copayment or Coinsurance.
Request for Medical Necessity Review. If you or your Physician believes a Brand Drug is Medically Necessary, either
person may request a Medical Necessity Review. If approved, the Brand Drug will be covered at the applicable Drug
tier Copayment or Coinsurance.
Short-Cycle Specialty Drug program. This program allows initial prescriptions for select Specialty Drugs to be filled for a
15-day supply with your approval. When this occurs, the Copayment or Coinsurance will be pro-rated.
Specialty Drugs. Specialty Drugs are only available from a Network Specialty Pharmacy, up to a 30-day supply.
Oral Anticancer Drugs. You pay up to $250 for oral Anticancer Drugs from a Participating Pharmacy, up to a 30-day
supply. Oral Anticancer Drugs from a Participating Pharmacy are not subject to any Deductible.
Mail service Drugs. You may receive up to a 90-day supply for maintenance Drugs from the mail service pharmacy
when you pay the applicable retail pharmacy Copayment or Coinsurance for each 30-day supply.
10 Pediatric Dental Coverage:

Pediatric dental Benefits are provided through Blue Shield’s Dental Plan Administrator (DPA).
Orthodontic Covered Services. The Copayment or Coinsurance for Medically Necessary orthodontic Covered Services
applies to a course of treatment even if it extends beyond a Calendar Year. This applies as long as the Member remains
enrolled in the Plan.
Teledentistry. To the extent this Plan offers teledentistry, it is offered at no charge.
Administration of these plan designs must comply with requirements of the pediatric dental EHB benchmark plan,
including coverage of services in circumstances of Medical Necessity as defined in the Early Periodic Screening,
Diagnosis and Treatment (EPSDT) benefit.
These endnotes do not limit an issuer’s obligations to comply with applicable federal, state, or local laws, rules, or
regulations. In the event an issuer is subject to a newly enacted or amended law, rule, or regulation that conflicts with
the requirements of these endnotes, an issuer shall comply with the law, rule, or regulation and any applicable
guidance from its regulatory authority. Where these endnotes exceed requirements imposed by law, an issuer shall
comply with the requirements in these endnotes.
11 Pediatric Vision Coverage:

Pediatric vision Benefits are provided through Blue Shield’s Vision Plan Administrator (VPA).
Covered Services from Non-Participating Providers. There is no Copayment or Coinsurance up to the listed Allowable
Amount. You pay all charges above the Allowable Amount.
15
Coverage for frames. If frames are selected that are more expensive than the Allowable Amount established for
frames under this Benefit, you pay the difference between the Allowable Amount and the provider’s charge.
“Collection frames” are covered with no Member payment from Participating Providers. Retail chain Participating
Providers do not usually display the frames as “collection,” but a comparable selection of frames is maintained.
“Non-collection frames” are covered up to an Allowable Amount of $150; however, if the Participating Provider
uses:
• wholesale pricing, then the Allowable Amount will be up to $103.64.
Participating Providers using wholesale pricing are identified in the provider directory.
Plans may be modified to ensure compliance with State and Federal requirements.
16
17
Introduction
Welcome! We are happy to have you as a Member of our Blue Shield of California (Blue
Shield) health plan. This plan has been certified as a Qualified Health Plan by Covered
California, the state’s health insurance marketplace. When you purchase a plan
through Covered California, they will send us your enrollment information. Once you are
enrolled, Blue Shield will be your primary point of contact for questions about Benefits,
Premiums, payment due dates, providers, and your Cost Share for Covered Services.
At Blue Shield, our mission is to ensure all Californians have access to high-quality health
care at an affordable price. To achieve this mission, we pledge to:
• Provide personal service to you that is worthy of our family and friends; and
• Build deep, trusting relationships with providers to improve the quality of health
care and lower the cost.
A Blue Shield health plan will help you pay for medical care and provide you with
access to a network of doctors, Hospitals, and other Health Care Providers. The types of
services that are covered, the providers you can see, and your share of cost when you
receive care may vary depending on your plan.
About this Agreement

The Evidence of Coverage and Health Service Agreement is the contract between you
and Blue Shield. We will refer to it as the Agreement. The Agreement tells you:
• Your eligibility for coverage;
• When coverage begins and ends;
• How you can access care;
• Which services are covered under your plan;
• Which services are not covered under your plan;
• When and how you must get prior authorization for certain services; and
• Important financial concepts, such as Premium, Deductible, and Out-of-Pocket
Maximum.
This Agreement includes a Summary of Benefits section that lists your Cost Share for
Covered Services. Use this summary to figure out what your cost will be when you
receive care.
Please read this Agreement carefully. Some topics in this document are complex. For
additional explanation on these topics, you may be directed to a section at the back
of the Agreement called Other important information about your plan. Pay particular
attention to sections that apply to any special health care needs you may have. Be
sure to keep this Agreement in your files for future reference.
Tables and images

In this Agreement, you will see the following tables and images to highlight key
information:
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Introduction 18
This table provides easy access to information
Phone numbers and addresses
Answers to commonly-asked questions
Examples to help you better understand important concepts
This box tells you where to find additional information about a

specific topic.
This box alerts you to information that may require you to take
action.
“You” means the Member

In this Agreement, “you” or “your” means any Member enrolled in the plan, including
the Subscriber and all Dependents.
Capitalized words have a special meaning

Some words and phrases in this Agreement may be new to you. Key terms with a
special meaning within this Agreement are capitalized in this document and
explained in the Definitions section.
About this plan

This is a Preferred Provider Organization (PPO) plan. In a PPO plan, you have the
flexibility to choose the providers you see. You can receive care from Participating
Providers or Non-Participating Providers. See the How to access care section for
information about Participating and Non-Participating Providers.
How to contact Customer Service

If you have questions at any time, we’re here to help. Blue Shield’s website and app are
useful resources. Visit blueshieldca.com or use the Blue Shield mobile app to:
• Download forms;
• View or print a temporary ID card;
• Access recent claims;
• Find a doctor or other Health Care Provider; and
• Explore health topics and wellness tools.
Blue Shield contact information appears at the bottom of every page.
9705.
Introduction 19
Contacting Customer Service
If you need information about You should contact
Medical and prescription Drug Benefits, Blue Shield Customer Service:

including prior authorization and claims
(855) 836-9705
submission
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
Acupuncture services American Specialty Health Plans of

California, Inc. (ASH Plans):
(800) 678-9133 (TTY: (877) 710-2746)
American Specialty Health Plans of

California, Inc.
P.O. Box 509002
San Diego, CA 92150-9002
Prior authorization of radiological services National Imaging Associates:

(888) 642-2583
Mental Health and Substance Use Mental Health Customer Service:

Disorder services, including prior
(877) 263-9952
authorization
Mental Health Service Administrator
P.O. Box 719002
San Diego, CA 92171-9002
Pediatric dental Benefits Dental Customer Service:

(800) 286-7401

Dental Plan Administrator
425 Market Street, 15th Floor
San Francisco, CA 94105
Pediatric vision Benefits Vision Customer Service:

(855) 342-9105
If you are hearing impaired, you may contact Customer Service through Blue Shield’s
toll-free TTY number: 711.
9705.
20
This Agreement is a contract between you and Blue Shield
This Agreement is issued by Blue Shield of California (Blue Shield) to the Subscriber. Blue
Shield’s offer of coverage relies on statements made in the Subscriber’s application.
Blue Shield will provide Benefits to the Subscriber and any enrolled Dependents in
consideration of timely payment of Premiums in full. The Agreement between Blue
Shield and the Subscriber includes the following:
• This Evidence of Coverage and Health Service Agreement;
• The Summary of Benefits;
• The Premium Appendix;
• Any endorsements; and
• Any applications or enrollment forms.
IN WITNESS WHEREOF, this Evidence of Coverage and Health Service Agreement is
executed by Blue Shield of California through its duly authorized officer, to take effect
on the Subscriber's effective date of coverage.
9705.
21
Your bill of rights
As a Blue Shield Member, you have the right to:
Receive considerate and courteous care with respect for your right to personal
1
privacy and dignity.
Receive information about all health services available to you, including a clear
2
explanation of how to obtain them.
3 Receive information about your rights and responsibilities.
Receive information about your Blue Shield plan, the services we offer you, and
4
the Physicians and other Health Care Providers available to care for you.
5 Have reasonable access to appropriate medical and mental health services.
Participate actively with your Physician in decisions about your medical and
6 mental health care. To the extent the law permits, you also have the right to
refuse treatment.
A candid discussion of appropriate or Medically Necessary treatment options for

7
your condition, regardless of cost or Benefit coverage.
An explanation of your medical or mental health condition, and any proposed,

appropriate, or Medically Necessary treatment alternatives from your Physician,
8 so you can make an informed decision before you receive treatment. This
includes available success/outcomes information, regardless of cost or Benefit
coverage.
9 Receive Preventive Health Services.
Know and understand your medical or mental health condition, treatment plan,
10
expected outcome, and the effects these have on your daily living.
Have confidential health records, except when the state law (California) or
11 federal law requires or permits disclosure. With adequate notice, you have the
right to review your medical record with your Physician.
Communicate with, and receive information from, Customer Service in a

12
language you can understand.
Know about any transfer to another Hospital, including information as to why the
13
transfer is necessary and any alternatives available.
Be fully informed about the complaint and grievance process and understand
14
how to use it without the fear of an interruption in your health care.
9705.
Your bill of rights 22
As a Blue Shield Member, you have the right to:
Voice complaints or grievances about your Blue Shield plan or the care
15
provided to you.
Make recommendations on Blue Shield’s Member rights and responsibilities

16
policies.
9705.
23
Your responsibilities
As a Blue Shield Member, you have the responsibility to:
Carefully read all Blue Shield plan materials immediately after you are enrolled
so you understand how to:
1 • Use your Benefits;
• Minimize your out-of-pocket costs; and
• Follow the provisions of your plan as explained in the Agreement.
Maintain your good health and prevent illness by making positive health choices
2
and seeking appropriate care when you need it.
Provide, to the extent possible, information needed for you to receive

3
appropriate care.
Understand your health problems and take an active role in developing

4
treatment goals with your Physician, whenever possible.
Follow the treatment plans and instructions you and your Physician agree to and
5 consider the potential consequences if you refuse to comply with treatment
plans or recommendations.
Ask questions about your medical or mental health condition and make certain
6
that you understand the explanations and instructions you are given.
Make and keep medical and mental health appointments and inform your
7
Health Care Provider ahead of time when you must cancel.
Communicate openly with your Physician so you can develop a strong

8
partnership based on trust and cooperation.
9 Offer suggestions to improve the Blue Shield plan.
Help Blue Shield maintain accurate and current records by providing timely
10 information regarding changes in your address, family status, and other plan
coverage.
Notify Blue Shield as soon as possible if you are billed inappropriately or if you
11
have any complaints or grievances.
12 Treat all Blue Shield personnel respectfully and courteously.
Pay your Premiums, Copayments, Coinsurance, and charges for non-Covered

13
Services in full and on time.
14 Follow the provisions of the Blue Shield Medical Management Programs.
9705.
24
How to access care
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR
WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
Health care professionals and facilities

This plan covers care from Participating Providers and Non-Participating Providers. You
do not need a referral. However, some services do require prior authorization. See the
Medical Management Programs section for information about prior authorization.
Participating Providers
Participating Providers have a contract with Blue Shield and agree to accept Blue
Shield’s Allowable Amount as payment in full for Covered Services. As a result, your
Cost Share is less when you receive Covered Services from a Participating Provider.
Some services will not be covered unless you receive them from a Participating
Provider. See the Summary of Benefits section to find out which Covered Services
must be received from a Participating Provider.
If a provider leaves this plan’s network, the status of the provider will change from
Participating to Non-Participating.
Visit blueshieldca.com or use the Blue Shield mobile app and

click on Find a Doctor for a list of your plan’s Participating
Providers.
Non-Participating Providers
Non-Participating Providers do not have a contract with Blue Shield to accept Blue
Shield’s Allowable Amount as payment in full for Covered Services. Except for
Emergency Services, services received at a Participating Provider facility (Hospital,
Ambulatory Surgery Center, laboratory, radiology center, imaging center, or certain
other outpatient settings) under certain conditions, and services provided by a 988
center, Mobile Crisis Team, or other provider of Behavioral Health Crisis Services, you
will pay more for Covered Services from a Non-Participating Provider.
Non-Participating Providers at a Participating Provider facility

When you receive care at a Participating Provider facility, some Covered
Services may be provided by a Non-Participating Provider. Your Cost Share will
be the same as the amount due to a Participating Provider under similar
circumstances, and you will not be responsible for additional charges above the
Allowable Amount, unless the Non-Participating Provider provides you written
notice of what they may charge and you consent to those terms.
9705.
How to access care 25
Common types of providers
Primary Care Physicians (PCPs)
Other primary care providers, such as nurse practitioners and physician assistants
Physician Specialists, such as dermatologists and cardiologists
Physical, occupational, and speech therapists
Mental health providers, such as psychiatrists, psychologists, and licensed clinical

social workers
Hospitals
Freestanding labs and radiology centers
Ambulatory Surgery Centers
Benefit Administrators
Blue Shield contracts with Benefit Administrators to manage the Benefits listed in the
table below through their own network of providers. Benefit Administrators authorize
services, process claims, and address complaints and grievances for those Benefits on
behalf of Blue Shield. If you receive a Covered Service from a Benefit Administrator, you
should interact with the Benefit Administrator in the same way you would otherwise
interact with Blue Shield.
Blue Shield’s Benefit Administrators
Benefit Administrator Benefit
Dental Plan Administrator (DPA) Pediatric dental Benefits
Vision Plan Administrator (VPA) Pediatric vision Benefits
Mental Health Service Administrator Mental Health and Substance Use

(MHSA) Disorder services
ASH Plans Acupuncture services
Your Primary Care Physician

You are required to have a Primary Care Physician (PCP). However, you do not need to
visit your PCP or get a referral from your PCP before you receive care.
9705.
We do suggest your PCP be your first point of contact when you need Covered
Services. Your PCP can provide primary care and help direct you to specialized care.
Blue Shield will initially choose a PCP for you. However, you can change your PCP at
any time.
PCPs may be:
• General practitioners;
• Family practitioners;
• Internists;
• Obstetrician/gynecologists; or
• Pediatricians.
You do not need to choose the same PCP for each Member in your family.
Your PCP must be a Participating Provider. If your PCP leaves this plan’s network, Blue
Shield will choose a new PCP for you and notify you. To change your PCP, visit
blueshieldca.com.
ID cards
Blue Shield will provide the Subscriber and any enrolled Dependents with identification
cards (ID cards). Only you can use your ID card to receive Benefits. Your ID card is
important for accessing health care, so please keep it with you at all times. Temporary
ID cards are available at blueshieldca.com or on the Blue Shield mobile app.
Canceling appointments
If you are unable to keep an appointment, you should notify the provider at least 24
hours before your scheduled appointment. Some offices charge a fee for missed
appointments unless it is due to an emergency or you give 24-hour advance notice.
Continuity of care
Continuity of care may be available if:
• Blue Shield or the MHSA no longer contracts with your Former Participating
Provider for the services you are receiving; or
• You are a newly-covered Member whose previous health plan was withdrawn
from the market.
If your Former Participating Provider is no longer available to you for one of the reasons
noted above, Blue Shield or the MHSA will notify you of the option to continue
treatment with your Former Participating Provider.
You can request to continue treatment with your Former Participating Provider in the
situations described above if you are currently receiving the following care:
9705.
Continuity of care with a Former Participating Provider
Qualifying conditions Timeframe
Undergoing a course of institutional or 90 days from the date of receipt of

inpatient care notice of the termination of the Former
Participating Provider’s contract or until
the treatment concludes, whichever is
sooner
Acute conditions As long as the condition lasts
Maternal mental health condition 12 months after the condition’s diagnosis

or 12 months after the end of the
pregnancy, whichever is later
Ongoing pregnancy care, including care Up to 12 months

immediately after giving birth
Recommended surgery or procedure Within 180 days

documented to occur within 180 days
Ongoing treatment for a child up to 36 Up to 12 months

months old
Serious chronic condition Up to 12 months
Terminal illness The duration of the terminal illness
If a condition falls within a qualifying condition under federal and state law, the more
generous time frames would be followed.
To request continuity of care, visit blueshieldca.com and fill out the Continuity of Care
Application. Blue Shield will confirm your eligibility and may review your request for
Medical Necessity.
Under Federal law, the Former Participating Provider must accept Blue Shield’s or the
MHSA’s Allowable Amount as payment in full for the first 90 days of your ongoing care.
Once the provider accepts and your request is authorized, you may continue to see
the Former Participating Provider at the Participating Provider Cost Share.
See the Your payment information section for more information about the Allowable
Amount.
Second medical opinion

You can consult a Participating or Non-Participating Provider for a second medical
opinion in situations including but not limited to:
• You have questions about the reasonableness or necessity of the treatment plan;
9705.
• There are different treatment options for your medical condition;

• Your diagnosis is unclear;
• Your condition has not improved after completing the prescribed course of
treatment;
• You need additional information before deciding on a treatment plan; or
• You have questions about your diagnosis or treatment plan.
You do not need prior authorization from Blue Shield or your PCP for a second medical
opinion.
Care outside of California

If you need urgent or emergency medical care while traveling outside of California,
you’re covered. Blue Shield has relationships with health plans in other states, Puerto
Rico, and the U.S. Virgin Islands through the BlueCard® Program. The Blue Cross Blue
Shield Association can help you access care from participating and non-participating
providers in those geographic areas.
This Blue Shield plan provides limited coverage for health care services received outside
of the Plan Service Area. Out-of-Area Covered Health Care Services are restricted to
Emergency Services, Urgent Services, and Out-of-Area Follow-up Care. Any other
services will not be covered when processed through an Inter-Plan Arrangement unless
prior authorized by Blue Shield.
See the Out-of-area services section for more information

about receiving care while outside of California. To find
participating providers while outside of California, visit
bcbs.com.
Emergency Services
If you have a medical emergency, call 911 or seek immediate

medical attention at the nearest hospital.
The Benefits of this plan will be provided anywhere in the world for treatment of an
Emergency Medical Condition. Emergency Services are covered at the Participating
Provider Cost Share, even if you receive treatment from a Non-Participating Provider.
After you receive care, Blue Shield will review your claim for Emergency Services to
determine if your condition was in fact an Emergency Medical Condition. If you did not
require Emergency Services and did not reasonably believe an emergency existed, you
will be responsible for the Participating or Non-Participating Provider Cost Share for that
non-emergency Covered Service.
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If you cannot find a Participating Provider

Call Customer Service if you need help finding a Participating Provider who can
provide the care you need close to home. If a Participating Provider is not available,
you can ask to see a Non-Participating Provider at the Participating Provider Cost
Share. If the services cannot reasonably be obtained from a Participating Provider, we
will approve your request and you will only be responsible for the Participating Provider
Cost Share.
Other ways to access care

For non-emergencies, it may be faster and easier to access care in one of the following
ways. For more information, visit blueshieldca.com or use the Blue Shield mobile app.
Retail-based health clinics

Retail-based health clinics are conveniently located within stores and pharmacies.
They are staffed with nurse practitioners who can provide basic medical care on a
walk-in basis.
The Cost Share for Covered Services at a Participating retail-based health clinic is the
same as the Cost Share at your PCP’s office.
Teladoc
Teladoc, a Third-Party Corporate Telehealth Provider, provides health consultations
by phone or secure online video. Teladoc general medical Physicians can diagnose
and treat basic non-emergency medical conditions, and can also prescribe certain
medication. Teladoc mental health consultations are available for Members age 13
and older. Members under age 13 may obtain telebehavioral health services for
Mental Health and Substance Use Disorders from MHSA Participating Providers.
Teladoc is a supplemental service that is not intended to replace care from your PCP
or your MHSA Participating Provider.
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How to access Teladoc
Teladoc service Ways to access Availability
General medical Phone: 1-800-835-2362 24 hours a day, 7 days

a week by phone or
Online: secure online video
blueshieldca.com/teladoc
Consultations can be
requested on-demand
or by scheduled
appointment
Mental health Phone: 1-800-835-2362 7 a.m. to 9 p.m., 7

days a week by
Online: scheduled
blueshieldca.com/teladoc appointment only
Consultations must be
scheduled online and
cannot be requested
by phone
Telebehavioral health services

Online telebehavioral health services for Mental Health and Substance Use Disorders
are available through MHSA Participating Providers and are a Covered Service
regardless of your age. Telebehavioral health includes counseling services,
psychotherapy, and medication management with a mental health provider. If you
are currently receiving telebehavorial health services for Mental Health and
Substance Use Disorders, you can continue to receive those services with the MHSA
Participating Provider rather than switching to a Third-Party Corporate Telehealth
Provider. Visit blueshieldca.com and click on Find a Doctor to access the MHSA
network.
Urgent care centers

Urgent care centers are free-standing facilities that provide many of the same basic
medical services as a doctor's office, often with extended hours but similar Cost
Share.
If your condition is not an emergency, but you need treatment that cannot be
delayed, you can visit an urgent care center to receive care that is typically faster
and costs less than an emergency room visit.
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Ambulatory Surgery Centers

Many of the more common, uncomplicated, outpatient surgical procedures can be
performed at an Ambulatory Surgery Center. Your cost at an Ambulatory Surgery
Center may be less than it would be for the same outpatient surgery performed at a
Hospital.
Evaluations and services under the CARE Act

Blue Shield covers the cost of developing an evaluation and the provision of all
health care services for an enrollee when required or recommended pursuant to a
CARE (Community Assistance, Recovery, and Empowerment) agreement or CARE
plan approved by a court in accordance with the CARE Act. The evaluation and
services, other than prescription Drugs, are covered at no charge whether they are
provided by a Participating or Non-Participating Provider.
Timely access to care

Participating Providers agree to provide timely access to care. This means that when
you call for an appointment, you will see your provider within a reasonable timeframe.
Blue Shield’s access standards are listed below.
When your appointment will occur
Urgent appointments Appointment will occur
Services that do not require prior Within 48 hours

authorization
Services that do require prior Within 96 hours

authorization
Urgent pediatric dental care Within 72 hours
Non-urgent appointments Appointment will occur
Primary Care Physician office visit Within 10 business days
Specialist office visit Within 15 business days
Mental or substance use disorder health

provider (who is not a Physician) office Within 10 business days
visit
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When your appointment will occur
Within 10 business days of the prior

Follow-up appointments with a mental or appointment for those undergoing a
substance use disorder health provider course of treatment for an ongoing
(who is not a Physician) mental health or substance use disorder
condition
Other services to diagnose or treat a

Within 15 business days
health condition
Non-urgent pediatric dental care Within 30 business days
Preventive pediatric dental care Within 40 business days
Phone inquiries Appointment will occur
Access to a health care professional for

phone triage or screening services by 24 hours a day, seven days a week
calling Customer Service
Call Customer Service if you need help finding a Participating Provider or if a

Participating Provider is not available. Please see the If you cannot find a Participating
Provider section for more information.
Contact Customer Service to schedule interpreter services for

your appointment. For more information about interpreter
services, see the Language access services notice.
Health advice and education

Blue Shield provides several ways for you to get health advice and access to health
education and wellness services. These resources are available to you at no extra cost.
NurseHelp 24/7SM
You can contact a registered nurse 24 hours a day, seven days a week through the
NurseHelp 24/7SM program. Nurses are available to help you select appropriate care
and answer questions about:
• Symptoms you are experiencing;
• Minor illnesses and injuries;
• Medical tests and medications;
• Chronic conditions; and
• Preventive care.
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Call (877) 304-0504 or log in to your account at blueshieldca.com and use the chat
feature to connect with a nurse. This service is free and confidential.
NurseHelp 24/7 SM is not meant to replace the advice and care you receive from your
Physician or other health care professional.
Health and wellness resources

Your Blue Shield coverage gives you access to a variety of health education and
wellness services, such as:
• Prenatal and other health education programs;
• Healthy lifestyle programs to help you get more active, quit smoking, lower
stress, and much more; and
• A health update newsletter.
Visit blueshieldca.com to explore these resources.
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Medical Management Programs
The Medical Management Programs are services that can help you coordinate your
care and treatment. They include utilization management and care management.
Blue Shield uses utilization management to help you and your providers identify the
most appropriate and cost-effective way to use the Benefits of this plan. Care
management and palliative care can help you access the care you need to manage
serious health conditions and complex treatment plans.
For written information about Blue Shield’s Utilization

Management Program, visit blueshieldca.com.
Prior authorization
Coverage for some Benefits requires pre-approval from Blue Shield. This process is called
prior authorization. Prior authorization requests are reviewed for Medical Necessity,
available plan Benefits, and clinically appropriate setting. The prior authorization
process also identifies Benefits that are only covered from Participating Providers or in a
specific clinical setting.
If you see a Participating Provider, your provider must obtain prior authorization when
required. When prior authorization is required but not obtained, Blue Shield may deny
payment to your provider. You are not responsible for Blue Shield’s portion of the
Allowable Amount if this occurs, only your Cost Share.
If you see a Non-Participating Provider, you or your provider must obtain prior
authorization when required. When prior authorization is required but not obtained, and
the services provided are determined not to be a Benefit of the plan or Medically
Necessary, Blue Shield may deny payment and you will be responsible for all billed
charges.
You do not need prior authorization for Emergency Services or emergency Hospital
admissions at Participating or Non-Participating facilities. For non-emergency inpatient
services, your provider should request prior authorization at least five business days
before admission.
Visit blueshieldca.com and click on Prior Authorization List for more details about
medical and surgical services and select prescription Drugs that require prior
authorization.
Prescription Drugs administered by a Health Care Provider

Drugs administered by a Health Care Provider in a Physician’s office, an infusion
center, the Outpatient Department of a Hospital, or provided at home through a
home infusion agency, are covered under the medical benefit and require prior
authorization.
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Medical Management Programs 35
The prior authorization process for self-administered prescription Drugs available at a

retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits
section.
Benefits are provided for COVID-19 therapeutics approved or granted emergency
use authorization by the U.S. Food and Drug Administration for treatment of COVID-
19 when prescribed or furnished by a Health Care Provider acting within their scope
of practice and the standard of care. Coverage is provided without a Cost Share for
services provided by a Participating Provider.
For a disease for which the Governor of the State of California has declared a public
health emergency, therapeutics approved or granted emergency use authorization
by the U.S. Food and Drug Administration for that disease will be covered without a
Cost Share.
Frequently-utilized services that require prior authorization
Benefit Services that require prior authorization
Medical and • Surgery

prescription Drug • Prescription Drugs administered by a Health Care
Provider
• Non-emergency inpatient facility services, such as
Hospitals and Skilled Nursing Facilities
• Non-emergency ambulance services
• Routine patient care received while enrolled in a
clinical trial
• Hospice program enrollment
Advanced imaging • CT (Computerized Tomography) scan

• MRI (Magnetic Resonance Imaging)
• MRA (Magnetic Resonance Angiography)
• PET (Positron Emission Tomography) scan
• Diagnostic cardiac procedure utilizing nuclear
medicine
Mental Health and • Non-emergency mental health or substance use

Substance Use disorder Hospital admissions, including acute and
Disorder residential care
• Behavioral Health Treatment
• Electroconvulsive therapy
• Psychological testing
• Partial Hospitalization Program
• Intensive Outpatient Program
• Transcranial magnetic stimulation
Pediatric dental • A course of treatment that is expected to cost more

than $250
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Frequently-utilized services that require prior authorization
Benefit Services that require prior authorization
Pediatric vision • Non-elective (Medically Necessary) contact lenses

• Low Vision testing and equipment
When a decision will be made about your prior authorization request
Prior authorization or exception request Time for decision
Routine medical, Mental Health and Substance Use Within five business days
Disorder, dental, and vision requests
Expedited medical, Mental Health and Substance Use Within 72 hours

Disorder, dental, and vision requests
Routine prescription Drug requests Within 72 hours
Expedited prescription Drug requests Within 24 hours
Once a decision is made for routine Mental Health and Substance Use Disorder
requests, a written notice will be sent to you and your provider within five calendar
days. For urgent Mental Health and Substance Use Disorder requests, a written notice
will be sent to you and your provider within 72 hours.
Expedited requests include urgent medical and exigent pharmacy requests. Once the
decision is made, your provider will be notified within 24 hours. Written notice will be sent
to you and your provider within two business days.
While you are in the Hospital (inpatient utilization review)

When you are admitted to the Hospital, your stay will be monitored for continued
Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient
level of care, Blue Shield will send a written notice to you, your provider, and the
Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you
will be financially responsible for all inpatient charges after that date. Exceptions to
inpatient utilization review include maternity and mastectomy care.
For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal
delivery and 96 hours for a C-section. The provider and mother together may decide
that a shorter length of stay is adequate.
For mastectomy, you and your provider determine the Medically Necessary length of
stay after the surgery.
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After you leave the Hospital (discharge planning)

You may still need care at home or in another facility after you are discharged from the
Hospital. Blue Shield will work with you, your provider, and the Hospital’s discharge
planners to determine the most appropriate and cost-effective way to provide this
care.
Using your Benefits effectively (care management)

Care management helps you coordinate your health care services and make the most
efficient use of your plan Benefits. Its goal is to help you stay as healthy as possible while
managing your health condition, to avoid unnecessary emergency room visits and
repeated hospitalizations, and to help you with the transition from Hospital to home. A
Blue Shield care management nurse may contact you to see how we might help you
manage your health condition. You may also request care management support by
calling Customer Service. A case manager can:
• Help you identify and access appropriate services;
• Instruct you about self-management of your health care conditions; and
• Identify community resources to lend support as you learn to manage a chronic
health condition.
Alternative services may be offered when they are medically appropriate and only
utilized when you, your provider, and Blue Shield mutually agree. The availability of
these services is specific to you for a set period of time based on your health condition.
Blue Shield does not give up the right to administer your Benefits according to the terms
of this Agreement or to discontinue any alternative services when they are no longer
medically appropriate. Blue Shield is not obligated to cover the same or similar
alternative services for any other Member in any other instance.
Managing a serious illness (palliative care services)

Blue Shield covers palliative care services if you have a serious illness. Palliative care
provides relief from the symptoms, pain, and stress of a serious illness to help improve
the quality of life for you and your family.
Palliative care services include access to Physicians and case managers who are
specially trained to help you:
• Manage your pain and other symptoms;
• Maximize your comfort, safety, autonomy, and well-being;
• Navigate a course of care;
• Make informed decisions about therapy;
• Develop a survivorship plan; and
• Document your quality-of-life choices.
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Your payment information
Paying for coverage

The Subscriber is responsible for a monthly payment to Blue Shield for health care
coverage. This monthly payment is a Premium. The Premium Appendix is a document
the Subscriber receives at the time of enrollment or renewal. It includes the monthly
Premium for this plan.
How to pay Premiums

Blue Shield offers a variety of ways for the Subscriber to pay Premiums.
Premium payments
Payment method How to pay
Mail Mail payment to:

P.O. Box 4700
Whittier, CA 90607-4700
Phone Call (855) 836-9705
Online Log in to blueshieldca.com and click on Payment

Center
Auto-pay Easy$Pay℠ from your checking or savings account
Visit blueshieldca.com for more information on Premium payment options.
Changes to Premiums
Blue Shield may change your Premium as the law permits. Blue Shield can change
your Premium if:
• A federal, state, or other taxing or licensing authority imposes a tax or fee;
• Blue Shield’s federal income tax associated with federal excise tax increases;
• Federal or state law requires it; or
• You relocate to a different geographic rating region.
Premiums may vary due to differences in the cost of health care services within each
geographic rating region.
Blue Shield will give the Subscriber written notice at least 10 days before the open
enrollment period each year, or 60 days prior to plan renewal, of any Premium
change.
Your Premiums may change without written notice when:
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Your payment information 39
• You move to a new geographic rating region. Your new Premium is effective the
first of the month after your last billing cycle.
• You add or drop a Dependent. For more information about changing
Dependents, see the Enrollment and effective dates of coverage section.
Paying for Covered Services

Your Cost Share is the amount you pay for Covered Services. It is your portion of the
Blue Shield Allowable Amount.
Your Cost Share includes any:
• Deductible;
• Copayment amount; and
• Coinsurance amount.
See the Summary of Benefits section for your Cost Share for
Covered Services.
Allowable Amount
The Allowable Amount is the maximum amount Blue Shield will pay for Covered
Services, or the provider’s billed charge for those Covered Services, whichever is less.
Blue Shield’s payment to the provider is the difference between the Allowable
Amount and your Cost Share.
Participating Providers agree to accept the Allowable Amount as payment in full for
Covered Services, except as stated in the Exception for other coverage and
Reductions – third party liability sections. When you see a Participating Provider, you
are responsible for your Cost Share.
Generally, Blue Shield will pay its portion of the Allowable Amount and you will pay
your Cost Share. If there is a payment dispute between Blue Shield and a
Participating Provider over Covered Services you receive, the Participating Provider
must resolve that dispute with Blue Shield. You are not required to pay for Blue
Shield’s portion of the Allowable Amount. You are only required to pay your Cost
Share for those services.
Non-Participating Providers do not agree to accept the Allowable Amount as
payment in full for Covered Services. When you see a Non-Participating Provider, you
are responsible for:
• Your Cost Share; and
• All charges over the Allowable Amount.
Calendar Year Deductible

The Deductible is the amount you pay each Calendar Year for Covered Services
before Blue Shield begins payment. Blue Shield will pay for some Covered Services
before you meet your Deductible.
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Amounts you pay toward your Deductible count toward your Out-of-Pocket
Maximum.
Some plans do not have a Deductible. For plans that do, there may be separate
Deductibles for:
• An individual Member and an entire Family;
• Participating Providers and Non-Participating Providers; and
• Medical and pharmacy Benefits.
If you have a Family plan, there is an individual Deductible within the Family
Deductible. This means an individual family member can meet the individual
Deductible before the entire Family meets the Family Deductible.
If you have an individual plan and you enroll a Dependent, your plan will become a
Family plan. Any amount you have paid toward the Deductible for your individual
plan will be applied to both the individual Deductible and the Family Deductible for
your new plan.
See the Summary of Benefits section for details on which Covered Services are
subject to the Deductible and how the Deductible works for your plan.
Copayment and Coinsurance

A Covered Service may have a Copayment or a Coinsurance. A Copayment is a
specific dollar amount you pay for a Covered Service. A Coinsurance is a
percentage of the Allowable Amount you pay for a Covered Service.
Your provider will ask you to pay your Copayment or Coinsurance at the time of
service. For Covered Services that are subject to your plan’s Deductible, you are also
responsible for all costs up to the Allowable Amount until you reach your Deductible.
You will continue to pay the Copayment or Coinsurance for each Covered Service
you receive until you reach your Out-of-Pocket Maximum.
Calendar Year Out-of-Pocket Maximum

The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for
Covered Services in a Calendar Year. Your Cost Share includes Deductible,
Copayment, and Coinsurance and these amounts count toward your Out-of-Pocket
Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum,
Blue Shield will pay 100% of the Allowable Amount for Covered Services for the rest of
the Calendar Year. If you want information about your Out-of-Pocket Maximum, you
can call Customer Service.
Some plans may have a separate Out-of-Pocket Maximum for:
• An individual Member and an entire Family;
• Participating Providers and Non-Participating Providers; and
• Participating Providers and combined Participating and Non-Participating
Providers.
If you have a Family plan, there is an individual Out-of-Pocket Maximum within the
Family Out-of-Pocket Maximum. This means an individual family member can meet
the individual Out-of-Pocket Maximum before the entire Family meets the Family
Out-of-Pocket Maximum.
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If you have an individual plan and you enroll a Dependent, your plan will become a
Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your
individual plan will be applied to both the individual Out-of-Pocket Maximum and
the Family Out-of-Pocket Maximum for your new plan.
The following do not count toward your Out-of-Pocket Maximum:
• Charges for services that are not covered; and
• Charges over the Allowable Amount.
You will continue to be responsible for these costs even after you reach your Out-of-
Pocket Maximum.
See the Summary of Benefits section for details on how the Out-of-Pocket Maximum
works for your plan.
Accrual balance
Blue Shield provides a summary of your accrual balances toward your Calendar Year
Deductible, if any, and Out-of-Pocket Maximum for every month in which your
Benefits were used until the full amount has been met. This summary will be mailed to
you unless you opt to receive it electronically or have already opted out of paper
mailings. You can opt back in to receive paper mailings at any time or elect to
receive your balance summary electronically by logging into your member portal
online and updating your communication preferences, or by calling Customer
Service at the number on the back of your ID card. You can also check your accrual
balances at any time by logging into your member portal online, which is updated
daily, or calling Customer Service. Your accrual balance information is updated
once a claim is received and processed and may not reflect recent services.
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Cost Share concepts in action

To recap, you are responsible for all costs for Covered Services until you reach your
Deductible. Once you reach your Deductible, Blue Shield will pay the Allowable
Amount for Covered Services, minus your Copayment or Coinsurance amounts, until
you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket
Maximum, Blue Shield will pay 100% of the Allowable Amount for Covered Services.
Exceptions are described above.
EXAMPLE
Cost to visit the doctor
Now that you know the basics, here is an example of how your Cost Share
works. Please note, the DOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES
ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.
Example: You visit the doctor for a sore throat. You have received Covered
Services throughout the year and have already met your $500 Deductible.
However, you have not yet met your $1,000 Out-of-Pocket Maximum.
Deductible: $500
Amount paid to date toward Deductible: $500
Out-of-Pocket Maximum: $1,000
Amount paid to date toward Out-of-Pocket Maximum: $500
Participating Provider Copayment: $30
Non-Participating Provider Copayment: $40
Blue Shield Allowable Amount for the doctor’s visit: $100
Non-Participating Provider billed charge for the doctor’s visit: $140
Participating Provider Non-Participating

Provider
You pay $30 $80

($30 Copayment) ($40 Copayment plus
$40 for charges over
Allowable Amount)
Blue Shield pays $70 $60

(Allowable Amount minus (Allowable Amount
your Cost Share) minus your Cost
Share)
Total payment to the $100 $140

doctor (Allowable Amount) (Billed charge)
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In this example, because you have already met your Deductible, you are responsible
for:
• Participating Provider: the Copayment; or
• Non-Participating Provider: the Copayment plus all charges over the Allowable
Amount.
Claims
When you receive health care services, a claim must be submitted to request payment
for Covered Services. A claim must be submitted even if you have not yet met your
Deductible. Blue Shield uses claims information to track dollar amounts that count
toward your Deductible.
When you see a Participating Provider, your provider submits the claim to Blue Shield.
When you see a Non-Participating Provider, you must submit the claim to Blue Shield or
the Benefit Administrator.
Claim forms are available at blueshieldca.com/covered-california-policies or by
contacting the Benefit Administrator. Please submit your claim form and medical
records within one year of the service date.
How to submit a claim
Type of claim What to submit Where to submit it Due date
Medical services • Blue Shield claim Blue Shield of California Within one
form; and P.O. Box 272540 year of the
• The itemized bill Chico, CA 95927 service date
from your provider
Pharmacy services • Prescription Drug Blue Shield of California Within one

claim form; and 1606 Ave. Ponce de year of the
• Related receipts Leon service date
or the pharmacy’s San Juan, PR 00909-
bill 4830
Mental Health and • Blue Shield claim Blue Shield of California Within one
Substance Use form; and P.O. Box 272540 year of the
Disorder services • The itemized bill Chico, CA 95927 service date
from your provider
Pediatric dental • Dental claim form; Blue Shield of California Within one
services and Dental Plan year of the
• Related receipts Administrator service date
or the provider’s P.O. Box 30567
bill Salt Lake City, UT 84130-
0567
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How to submit a claim
Type of claim What to submit Where to submit it Due date
Pediatric vision • Vision claim form; Blue Shield of California Within one
services and Vision Plan year of the
• Related receipts Administrator service date
or the provider’s Attn: OON Claims
bill P.O. Box 8504
Mason, OH 45040-7111
Claim processing and payments

Blue Shield or the Benefit Administrator will process your claim within 30 business days
of receipt if it is not missing any required information. If your claim is missing any
required information, you or your provider will be notified and asked to submit the
missing information. Blue Shield cannot process your claim until we receive the
missing information.
Once your claim is processed, you will receive an explanation of your Benefits. For
each service, the explanation will list your Cost Share and the payment made by
Blue Shield or the Benefit Administrator to the provider.
When you receive Covered Services from a Non-Participating Provider, Blue Shield or
the Benefit Administrator may send the payment to the Subscriber, or directly to the
Non-Participating Provider.
The Subscriber must make sure the Non-Participating Provider

receives the full billed amount for non-emergency services,
whether or not Blue Shield makes payment to the Non-
Participating Provider.
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45
Your coverage
This section explains eligibility and enrollment for this plan. It also describes the terms of
your coverage, including information about effective dates and the different ways your
coverage can end.
Eligibility for this plan

Covered California determines if you are a Qualified Individual eligible to enroll and
continue enrollment in this plan. To enroll in this plan, you must be a Resident of
California.
Visit coveredca.com for more information about Covered

California eligibility requirements.
Dependent eligibility
To be eligible for coverage as a Dependent, the individual must meet all eligibility
requirements listed above, as well as certain Covered California Dependent eligibility
requirements. The individual must:
• Be listed on the enrollment form completed by the Subscriber; and
• Be the Subscriber’s spouse, Domestic Partner, qualifying parent or stepparent, or
be under age 26 and the child of the Subscriber, spouse, or Domestic Partner.
o For the Subscriber’s spouse to be eligible for this plan, the Subscriber and
spouse must not be legally separated.
o For the Subscriber’s Domestic Partner to be eligible for this plan, the
Subscriber and Domestic Partner must have a registered domestic
partnership.
o A qualifying parent or stepparent has a Calendar Year gross income as
provided in Section 151(d) of the United States Code and the Subscriber
provides more than half of their financial support during the Calendar
Year.
o “Child” includes a stepchild, newborn, child placed for adoption, child
placed in foster care, and child for whom the Subscriber, spouse, or
Domestic Partner is the legal guardian. It does not include a grandchild
unless the Subscriber, spouse, or Domestic Partner has adopted or is the
legal guardian of the grandchild.
o A child age 26 or older can remain enrolled as a Dependent if the child is
disabled, incapable of self-support because of a mental or physical
disability, and chiefly dependent on the Subscriber for economic support.
▪ The Dependent child’s disability must have begun before the period
he or she would become ineligible for coverage due to age.
▪ Blue Shield will send a notice of termination due to loss of eligibility 90
days before the date coverage will end. The Subscriber must inform
Covered California of the Dependent’s eligibility for continuation of
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Your coverage 46
coverage within 60 days of receipt of this notice in order to continue

coverage.
▪ The Subscriber must submit proof of continued eligibility for the
Dependent at Blue Shield’s request. Blue Shield may not request this
information again for two years after the initial determination. Blue
Shield may request this information no more than once a year after
that. The Subscriber’s failure to provide this information could result in
termination of a Dependent’s coverage.
Enrollment and effective dates of coverage

As the Subscriber, you can apply for coverage for yourself and your Dependents during
the annual open enrollment period. You can also apply for coverage for yourself and
your Dependents if you qualify for a special enrollment period.
This Agreement covers the Subscriber and any enrolled Dependents for one plan year.
A plan year begins on January 1 and ends on December 31 of that same year.
The date coverage starts for the Subscriber and any enrolled Dependents is the
effective date of coverage. Coverage starts at 12:01 a.m. Pacific Time on the effective
date of coverage. The Benefits of this plan are not available before the effective date
of coverage. Blue Shield will notify you of your effective date of coverage.
Open enrollment period

The open enrollment period is the time when most people apply for coverage or
change coverage. California law establishes the open enrollment period each year.
Visit blueshieldca.com for more information about open enrollment, including this
year’s dates.
Special enrollment period

A special enrollment period is a time outside open enrollment when you can apply
for coverage or change coverage. A special enrollment period begins with a
Triggering Event.
A special enrollment period gives you at least 60 days from a Triggering Event to
apply for or change coverage for yourself or your Dependents. See the Special
enrollment period section for more information. You should notify Covered California
as soon as possible if you experience a Triggering Event that requires a change in
your coverage.
If you qualify for a special enrollment period and coverage begins in the middle of a
plan year, your coverage under this Agreement will be less than a full year and will
end on December 31 of the year coverage began.
Common Triggering Events
Change in Dependents
Move within California under certain circumstances
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Common Triggering Events
Loss of minimum essential coverage
Loss of eligibility in a government program
For a complete list of Triggering Events, see Special enrollment

period on page 98 in the Other important information about
your plan section.
Effective date of coverage for most special enrollment periods

If enrolled during open enrollment, Dependents have the same effective date of
coverage as the Subscriber. However, a Dependent may have a different
effective date of coverage if added during a special enrollment period.
Generally, if the Subscriber submits an application or request for special
enrollment, the effective date of coverage will be the 1st of the next month.
Effective date of coverage for a new spouse or Domestic Partner

The effective date of coverage for a new spouse or Domestic Partner will be the
1st of the month following the date the Subscriber submits the Dependent
enrollment application. This applies regardless of what day of the month the
Subscriber submits the application.
Effective date of coverage for a new Dependent child

Coverage starts immediately for a:
• Newborn;
• Adopted child;
• Child placed for adoption;
• Child placed in foster care; or
• Child for whom the Subscriber, spouse, or Domestic Partner is the court-
appointed legal guardian.
For coverage to continue beyond 31 days, the Subscriber must

enroll the child through Covered California within 60 days of
birth, adoption, placement for adoption, placement in foster
care, or the date of court-ordered guardianship.
A child will be considered adopted for the purpose of Dependent eligibility when
one of the following happens:
• The child is legally adopted;
• The child is placed for adoption and there is evidence of the Subscriber,
spouse, or Domestic Partner’s right to control the child’s health care; or
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• The Subscriber, spouse, or Domestic Partner is granted legal authority to

control the child’s health care.
The child’s eligibility as a Dependent will continue while waiting for a legal
decree of adoption unless the child is removed from the Subscriber, spouse, or
Domestic Partner’s home before the decree is issued.
Terms of coverage
The Subscriber’s option to renew this coverage is guaranteed, except as the law
permits. The Subscriber must pay Premiums in full within the required timeframe, and the
Subscriber and Dependents must maintain eligibility.
The Subscriber must notify Covered California within 60 days of any changes that will
affect the eligibility of the Subscriber or an enrolled Dependent. Blue Shield is not
obligated to pay for Benefits for an ineligible individual, even if the Subscriber continues
to pay Premiums for that individual.
Blue Shield has the right to change this plan, as the law permits. This includes changes
to:
• Terms and conditions;
• Benefits;
• Premiums; and
• Limitations and exclusions.
Blue Shield will not change terms and conditions, Benefits, or limitations and exclusions
on an individual basis. If Blue Shield changes this Agreement, the change will affect
everyone covered under this plan. Blue Shield will give the Subscriber written notice of
any changes to the Agreement. We will send this notice at least 10 days before the
open enrollment period each year, or 60 days prior to plan renewal.
Your Premiums may change without written notice when you initiate the type of
change described in the Changes to Premiums section.
When coverage ends

Your coverage will end if:
• The Subscriber cancels or does not renew coverage;
• Blue Shield or Covered California cancels or does not renew coverage; or
• Blue Shield or Covered California rescinds coverage.
There is no right to receive the Benefits of this plan after coverage ends, except as
described in the Continuity of care section.
If the Subscriber pays Premiums beyond the date coverage ends, those Premiums are
unearned. Blue Shield will refund unearned Premiums to the Subscriber, minus any
amount Blue Shield pays for Benefits received after the date coverage ends. Blue Shield
will only issue a refund to the Subscriber if the amount the Subscriber paid in unearned
Premiums is more than the amount Blue Shield pays for Benefits after coverage ends.
If the Subscriber cancels or does not renew coverage

The Subscriber can cancel coverage by giving Covered California 14 days’ notice.
Coverage will end at 11:59 p.m. Pacific Time on the effective date of termination.
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If the Subscriber decides to cancel coverage, the actual date coverage ends is
based on when the Subscriber gives notice to Covered California. Once the
Subscriber’s coverage is terminated, coverage under this plan cannot be reinstated.
However, you may reapply for coverage during open enrollment, or if you qualify for
special enrollment.
When coverage ends if the Subscriber cancels or does not renew
If the Subscriber gives Date coverage ends
14 days’ notice or more The date the Subscriber selects
Less than 14 days’ notice A date Covered California selects

that is at least 14 days after receipt of
your notice
If Blue Shield or Covered California cancels or does not renew coverage

Blue Shield or Covered California can cancel coverage or deny renewal, as the law
permits. If this happens, the date coverage ends depends on the reason for
cancellation or non-renewal.
Cancellation for Subscriber’s nonpayment of Premiums

Blue Shield can cancel your coverage if the Subscriber does not pay the
required Premiums in full and on time. The Subscriber is responsible for all
Premiums during the term of coverage, including the grace period. If Blue Shield
cancels coverage due to nonpayment of Premiums, Blue Shield will send the
Notice of TerminationSubscriber within five business days of the cancellation. This
notice will state:
• That the Agreement has been canceled;
• The reasons for cancellation; and
• The specific date and time when your coverage will end.
Premium grace period if you do not receive Advance Payments of Premium Tax
Credits
The Subscriber has a 30-day grace period to pay all outstanding Premiums
before coverage is canceled due to nonpayment of Premiums. Coverage will
continue during the grace period. Blue Shield will send a Notice of Start of Grace
Period to the Subscriber after the last date of paid coverage. The 30-day grace
period begins on the day the Notice of Start of Grace Period is dated. If the
Subscriber does not pay all outstanding Premiums within the grace period,
coverage will end the day following the 30-day grace period. The Subscriber will
be liable for all Premiums owed, even if coverage is canceled. This includes
Premiums owed for coverage during the 30-day grace period.
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Premium grace period if you receive Advance Payments of Premium Tax Credits
and/or State Advanced Premium Assistance Subsidy
If the Subscriber previously paid Blue Shield at least one full month’s Premium
during the benefit year and is late on a Premium payment, Blue Shield will notify
the Subscriber and the Subscriber will have a grace period of three consecutive
months from the due date to pay all outstanding Premiums. Blue Shield will pay
claims for Covered Services during the first month (or first 30 days, whichever is
greater) of the grace period. Coverage will be suspended for the second and
third months of the grace period until the Subscriber pays all Premiums owed.
If the three-month grace period expires before the Subscriber pays all
outstanding Premiums, Blue Shield will terminate coverage. The last day of
coverage will be the last day of the first month of the three-month grace period
(or 30 days from the first day of the first month, whichever is later).
Cancellation for fraud or intentional misrepresentation of material fact

Blue Shield or Covered California may cancel your coverage for fraud or
intentional misrepresentation of material fact if you:
• Intentionally provide false or misleading information to Blue Shield or
Covered California on the enrollment application or otherwise. This
includes incorrect or incomplete material information such as failing to
provide Blue Shield with required or requested information in a timely
manner;
• Let someone else use your ID card to receive services; or
• Receive, or attempt to receive, services by means of false, materially
misleading, or fraudulent information, acts, or omissions.
Blue Shield or Covered California rescinds coverage

IF THE SUBSCRIBER OR ANY ENROLLED DEPENDENT COMMITS FRAUD OR MAKES AN
INTENTIONAL MISREPRESENTATION OF MATERIAL FACT DURING THE APPLICATION
PROCESS, BLUE SHIELD OR COVERED CALIFORNIA CAN RETROACTIVELY CANCEL
COVERAGE. THIS INCLUDES FAILURE TO DISCLOSE ANY NEW OR CHANGED FACTS
PERTAINING TO THE APPLICATION THAT ARISE AFTER SUBMISSION OF THE APPLICATION
BUT BEFORE THE EFFECTIVE DATE OF COVERAGE. THIS RETROACTIVE CANCELLATION IS
RESCISSION.
If Blue Shield or Covered California rescinds coverage, Blue Shield will provide the
Subscriber with a 30-day written notice. This notice will state:
• The reason for the rescission;
• Information about the Subscriber’s right to appeal, including the right to request
assistance from the Department of Managed Health Care;
• Clarification that individuals whose application information was not false or
incomplete are entitled to new coverage, and:
o How those individuals may obtain new coverage; and
o How Blue Shield will determine Premiums for those individuals.
After your contract has been in effect for 24 months, Blue Shield or Covered
California cannot rescind coverage for any reason. If Blue Shield or Covered
California rescinds coverage, the Subscriber and any enrolled Dependents will lose
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all coverage dating back to the original effective date of coverage. It will be as if
coverage never existed.
When Blue Shield or Covered California cancels,
does not renew, or rescinds coverage
Reason Date coverage ends
Failure to pay Premiums in full and on 30 days after the date on the Notice
time, including the grace period of Start of Grace Period
Fraud or intentional misrepresentation The initial effective date of coverage

of a material fact during the
application process
Fraud or intentional misrepresentation 30 days after written notice to the

of a material fact after enrollment Subscriber
Loss of Subscriber eligibility 30 days after written notice to the

Subscriber
Loss of Dependent eligibility for a If notice of ineligibility is sent before

spouse or Domestic Partner the 15th of the month: The first day of
the month after notice is sent
If notice of ineligibility is sent after the
15th of the month: The first day of the
second month after notice is sent
Loss of Dependent eligibility for a child The last day of the year in which the
Dependent turns 26
Subscriber changes from one health The day before the effective date of
plan to another during open or special coverage in the Subscriber’s new
enrollment period plan
Request to enroll a newborn, adopted Day 31 following the initial coverage

child, or child placed for adoption is date
not received within 60 days of the
initial coverage date
Blue Shield no longer offers this 90 days after written notice to the
Individual and Family Plan Subscriber
Blue Shield no longer offers any 180 days after written notice to the
Individual and Family Plans Subscriber
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When Blue Shield or Covered California cancels,
does not renew, or rescinds coverage
Reason Date coverage ends
Subscriber was enrolled in a Qualified The initial effective date of coverage

Health Plan without his or her
knowledge or consent by a third party,
including by a third party with no
connection to Covered California
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Your Benefits
This section describes the Benefits your plan covers. They are listed in alphabetical order
so they are easy to find.
Blue Shield provides coverage for Medically Necessary services and supplies only.
Experimental or Investigational services and supplies are not covered.
All Benefits are subject to:
• Your Cost Share;
• Any Benefit maximums;
• The provisions of the Medical Management Programs; and
• The terms, conditions, limitations, and exclusions of this Agreement.
You can receive many outpatient Benefits in a variety of settings, including your home,
a Physician’s office, an urgent care center, an Ambulatory Surgery Center, or a
Hospital. Blue Shield’s Medical Management Programs work with your provider to
ensure that your care is provided safely and effectively in a setting that is appropriate
to your needs. Your Cost Share for outpatient Benefits may vary depending on where
you receive them.
See the Exclusions and limitations section for more information about Benefit exclusions
and limitations.
See the Summary of Benefits section for your Cost Share for
Covered Services.
Acupuncture services
For all acupuncture services, Blue Shield has contracted with American Specialty Health
Plans of California, Inc. (ASH Plans) to act as the Plan’s acupuncture services
administrator.
Benefits are available for acupuncture services for the treatment of nausea or as part of
a comprehensive pain management program for the treatment of chronic pain.
Acupuncture services must be provided by a Physician, licensed acupuncturist, or other
appropriately licensed or certified Health Care Provider.
Contact ASH Plans with questions about acupuncture services, ASH Participating
Providers, or acupuncture Benefits.
Allergy testing and immunotherapy Benefits

Benefits are available for allergy testing and immunotherapy services.
Benefits include:
• Allergy testing on and under the skin such as prick/puncture, patch and scratch
tests;
• Preparation and provision of allergy serum; and
• Allergy serum injections.
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This Benefit does not include:

• Blood testing for allergies.
Ambulance services
Benefits are available for ambulance services provided by a licensed ambulance or
psychiatric transport van.
Benefits include:
• Emergency ambulance transportation (surface and air) when used to transport
you from the place of illness or injury to the closest medical facility that can
provide appropriate medical care; and
• Non-emergency, prior-authorized ambulance transportation (surface and air)
from one medical facility to another.
Ambulance services are covered at the Participating Provider Cost Share, even if you
receive services from a Non-Participating Provider.
Bariatric surgery Benefits

Benefits are available for bariatric surgery services. These Benefits include facility and
Physician services for the surgical treatment of morbid obesity.
Services for residents of designated California counties

Blue Shield has a network of Participating Providers for bariatric surgery services in
certain designated counties within California. If you live in a designated county,
services are only covered if you receive them from one of these Participating
Providers.
Bariatric surgery services designated counties
Imperial Orange San Diego
Kern Riverside Santa Barbara
Los Angeles San Bernardino Ventura
Travel expense reimbursement for residents of designated counties

You may be eligible for reimbursement of your travel expenses for bariatric
surgery services if you meet the following conditions:
• Live in a designated county;
• Live at least 50 miles away from the nearest bariatric surgery services
provider in the network;
• Receive prior authorization for travel expense reimbursement; and
• Submit receipts and any other documentation of your expenses to Blue
Shield.
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Reimbursable bariatric surgery travel expenses
Maximum
Expense type Limitations & exclusions
reimbursement
• Maximum of 3 roundtrips
Transportation to $130/roundtrip
(pre-surgery, surgery, follow-
and from the
up)
facility
• 1 companion is covered for
a maximum of 2 roundtrips
(surgery & surgery follow-up)
• Maximum of 2 trips, 2
Hotel $100/day
days/trip (pre-surgery &
accommodations
post-surgery follow-up) for
you and 1 companion
• 1 companion alone may be
reimbursed for a maximum
of 4 days during your
surgery admission
• Hotel stays are limited to 1
double-occupancy room.
Only the room is covered.
All other hotel expenses are
excluded
• Maximum of 4 days/trip
Related $25/day/Member
• Expenses for tobacco,
reasonable
alcohol, drugs, phone,
expenses
television, delivery, and
recreation are excluded
Services for residents of non-designated counties

If you do not reside in a designated county, bariatric surgery services are covered
like other surgery services from Participating or Non-Participating Providers. See the
Hospital services and Physician and other professional services sections for more
information.
Blue Shield does not reimburse travel expenses associated with bariatric surgery
services for residents of non-designated counties.
Clinical trials for treatment of cancer or life-threatening diseases or

conditions Benefits
Benefits are available for routine patient care when you have been accepted into an
approved clinical trial for treatment of cancer or a life-threatening disease or condition.
A life-threatening disease or condition is a disease or condition that is likely to result in
death unless its progression is interrupted.
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The clinical trial must have therapeutic intent and the treatment must meet one of the
following requirements:
• Your Primary Care Physician, or another Participating Provider, determines that
your participation in the clinical trial would be appropriate based on either the
trial protocol or medical and scientific information provided by you; or
• You provide medical and scientific information establishing that your
participation in the clinical trial would be appropriate.
Coverage for routine patient care received while participating in a clinical trial requires
prior authorization. Routine patient care is care that would otherwise be covered by the
plan if those services were not provided in connection with an approved clinical trial.
The Summary of Benefits section lists your Cost Share for Covered Services. These Cost
Share amounts are the same whether or not you participate in a clinical trial. Routine
patient care does not include:
• The investigational item, device, or service itself;
• Drugs or devices not approved by the U.S. Food and Drug Administration (FDA);
• Travel, housing, companion expenses, and other non-clinical expenses;
• Any item or service that is provided solely to satisfy data collection and analysis
needs and that is not used in the direct clinical management of the patient;
• Services that, except for the fact that they are being provided in a clinical trial,
are specifically excluded under the plan;
• Services normally provided by the research sponsor free for any enrollee in the
trial; or
• Any service that is clearly inconsistent with widely accepted and established
standards of care for a particular diagnosis.
Approved clinical trial means a phase I, phase II, phase III, or phase IV clinical trial
conducted in relation to the prevention, detection, or treatment of cancer or other life-
threatening diseases or conditions, and the study or investigation meets one of the
following requirements:
• It is a drug trial conducted under an investigational new drug application
reviewed by the FDA;
• It is a drug trial exempt under federal regulations from a new drug application; or
• It is federally funded or approved by one or more of the following:
o One of the National Institutes of Health;
o The Centers for Disease Control and Prevention;
o The Agency for Health Care Research and Quality;
o The Centers for Medicare & Medicaid Services; or
o A designated Agency affiliate or research entity as described in the
Affordable Care Act, including the Departments of Veterans Affairs, Defense,
or Energy if the study has been reviewed and approved according to Health
and Human Services guidelines.
Diabetes care services

Benefits are available for devices, equipment, supplies, and self-management training
to help manage your diabetes. Services will be covered when provided by a Physician,
registered dietician, registered nurse, or other appropriately-licensed Health Care
Provider who is certified as a diabetes educator.
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Devices, equipment, and supplies

Covered diabetic devices, equipment, and supplies include:
• Blood glucose monitors, including continuous blood glucose monitors and those
designed to help the visually impaired, and all related necessary supplies;
• Insulin pens, syringes, pumps, and all related necessary supplies;
• Blood and urine testing strips and tablets;
• Lancets and lancet puncture devices;
• Podiatric footwear and devices to prevent or treat diabetes-related
complications;
• Medically Necessary foot care; and
• Visual aids, excluding eyewear and video-assisted devices, designed to help the
visually impaired with proper dosing of insulin.
Your plan also covers the replacement of a covered item after the expiration of its life
expectancy.
Self-management training and medical nutrition therapy

Benefits are available for outpatient training, education, and medical nutrition
therapy when directed or prescribed by your Physician. These services can help you
manage your diabetes and properly use the devices, equipment, and supplies
available to you. With self-management training, you can learn to monitor your
condition and avoid frequent hospitalizations and complications.
Diagnostic X-ray, imaging, pathology, laboratory, and other testing

services
Benefits are available for imaging, pathology, and laboratory services for preventive
screening or to diagnose or treat illness or injury.
Benefits include:
• Basic diagnostic imaging services, such as plain film X-rays, ultrasounds, and
mammography;
• Advanced diagnostic radiological and nuclear imaging, including CT, PET, MRI,
and MRA scans;
• COVID-19 diagnostic testing, screening testing, and related healthcare services.
Medical Necessity requirements do not apply for COVID-19 screening testing;
• Reimbursement for over-the-counter at-home COVID-19 tests. The
reimbursement is allowed for up to 8 tests per Member per month, subject to a
maximum reimbursement of $12 per test. See the Claims section for information
about how to submit a claim for repayment for this Benefit;
• Sexually transmitted disease home testing kits, including any laboratory costs of
processing the kit. A Physician or other Health Care Provider’s order must be
provided for coverage;
• Biomarker testing for the purposes of diagnosis, treatment, appropriate
management, or ongoing monitoring of your disease or condition to guide
treatment decisions. Benefits must be prior authorized;
• Clinical pathology services;
• Laboratory services;
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• Other areas of non-invasive diagnostic testing, including respiratory,

neurological, vascular, cardiological, genetic, cardiovascular, and
cerebrovascular; and
• Prenatal diagnosis of genetic disorders of the fetus in cases of high-risk
pregnancy.
Laboratory or imaging services performed as part of a preventive health screening are
covered under the Preventive Health Services Benefit.
For services provided by Participating Providers, Blue Shield will waive Cost Shares for
COVID-19 diagnostic testing, screening testing, and related services.
Blue Shield encourages Members to seek services from Participating Providers to avoid
paying extra fees. Some Non-Participating Providers may charge extra fees that are not
covered by Blue Shield. Any fees not covered by Blue Shield will be the Member’s
responsibility. See the How to access care section for information about Participating
and Non-Participating Providers.
Dialysis Benefits
Benefits are available for dialysis services at a freestanding dialysis center, in the
Outpatient Department of a Hospital, in a physician office setting or in your home.
Benefits include:
• Renal dialysis;
• Hemodialysis;
• Peritoneal dialysis; and
• Self-management training for home dialysis.
Benefits do not include:
• Comfort, convenience, or luxury equipment; or
• Non-medical items, such as generators or accessories to make home dialysis
equipment portable.
Durable medical equipment

Benefits are available for durable medical equipment (DME) and supplies needed to
operate the equipment. DME is intended for repeated use to treat an illness or injury, to
improve the function of movable body parts, or to prevent further deterioration of your
medical condition. Items such as orthotics and prosthetics are only covered when
necessary for Activities of Daily Living.
Benefits include:
• Mobility devices, such as wheelchairs;
• Peak flow meter for the self-management of asthma;
• Glucose monitor including continuous blood glucose monitor, and all related
necessary supplies for the self-management of diabetes;
• Apnea monitors for the management of newborn apnea;
• Home prothrombin monitor for specific conditions;
• Oxygen and respiratory equipment;
• Disposable medical supplies used with DME and respiratory equipment;
• Required dialysis equipment and medical supplies;
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• Medical supplies that support and maintain gastrointestinal, bladder, or bowel

function, such as ostomy supplies;
• DME rental fees, up to the purchase price; and
• Breast pumps.
• Environmental control and hygienic equipment, such as air conditioners,
humidifiers, dehumidifiers, or air purifiers;
• Exercise equipment;
• Routine maintenance, repair, or replacement of DME due to loss or misuse,
except when authorized;
• Self-help or educational devices;
• Speech or language assistance devices, except as specifically listed;
• Wigs;
• Adult eyewear;
• Video-assisted visual aids for diabetics;
• Generators;
• Any other equipment not primarily medical in nature; or
• Backup or alternate equipment.
Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefit.
See the Diabetes care services section for more information about devices, equipment,
and supplies for the management and treatment of diabetes.
Orthotic equipment and devices

Benefits are available for orthotic equipment and devices you need to perform
Activities of Daily Living. Orthotics are orthopedic devices used to support, align,
prevent, or correct deformities or to improve the function of movable body parts.
Benefits include:
• Shoes only when permanently attached to orthotic devices;
• Special footwear required for foot disfigurement caused by disease, disorder,
accident, or developmental disability;
• Knee braces for post-operative rehabilitation following ligament surgery,
instability due to injury, and to reduce pain and instability for patients with
osteoarthritis;
• Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and
used to treat mechanical problems of the foot, ankle, or leg by preventing
abnormal motion and positioning when improvement has not occurred with a
trial of strapping or an over-the-counter stabilizing device;
• Device fitting and adjustment;
• Device replacement at the end of its expected lifespan; and
• Repair due to normal wear and tear.
• Orthotic devices intended to provide additional support for recreational or sports
activities;
• Orthopedic shoes and other supportive devices for the feet, except as listed;
• Backup or alternate items; or
• Repair or replacement due to loss or misuse.
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Prosthetic equipment and devices

Benefits are available for prosthetic appliances and devices used to replace a part
of your body that is missing or does not function, and related supplies.
Benefits include:
• Tracheoesophageal voice prosthesis (e.g. Blom-Singer device) and artificial
larynx for speech after a laryngectomy;
• Artificial limbs and eyes;
• Internally-implanted devices such as pacemakers, intraocular lenses, cochlear
implants, osseointegrated hearing devices, and hip joints, if surgery to implant
the device is covered;
• Contact lenses to treat eye conditions such as keratoconus or keratitis sicca,
aniridia, or to treat aphakia following cataract surgery when no intraocular lens
has been implanted;
• Supplies necessary for the operation of prostheses;
• Device fitting and adjustment;
• Device replacement at the end of its expected lifespan; and
• Repair due to normal wear and tear.
• Speech or language assistance devices, except as listed;
• Dental implants;
• Backup or alternate items; or
• Repair or replacement due to loss or misuse.
Emergency Benefits
Benefits are available for Emergency Services received in the emergency room of a
Hospital or other emergency room licensed under state law. The Emergency Benefit
also includes Hospital admission when inpatient treatment of your Emergency Medical
Condition is Medically Necessary. You can access Emergency Services for an
Emergency Medical Condition at any Hospital, even if it is a Non-Participating Hospital.
If you have a medical emergency, call 911 or seek immediate

medical attention at the nearest hospital.
Benefits include:
• Physician services;
• Emergency room facility services; and
• Inpatient Hospital services to stabilize your Emergency Medical Condition.
After your condition stabilizes

Once your Emergency Medical Condition has stabilized, it is no longer considered an
emergency. Upon stabilization, you may:
• Be released from the emergency room if you do not need further treatment;
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• Receive additional inpatient treatment at the Participating Hospital; or

• Transfer to a Participating Hospital for additional inpatient treatment if you
received treatment of your Emergency Medical Condition at a Non-Participating
Hospital.
Stabilization is medical treatment necessary to assure, with reasonable medical
probability, that no material deterioration of the condition is likely to result from, or
occur during, your release from medical care or transfer from a facility. With respect
to a pregnant woman who is having contractions, when there is inadequate time to
safely transfer her to another Hospital before delivery or the transfer may pose a
threat to the health or safety of the woman or unborn child, stabilize means delivery,
including the placenta. Post-stabilization care is Medically Necessary treatment
received after the treating Physician determines the Emergency Medical Condition is
stabilized.
If you are admitted to the Hospital for Emergency Services, you should notify Blue
Shield within 24 hours or as soon as possible after your condition has stabilized.
Family planning Benefits

Benefits are available for family planning services without illness or injury.
Benefits include:
• Counseling, consulting, and education;
• Office-administered contraceptives;
• Physician office visits for office-administered contraceptives;
• Clinical services related to the provision or use of contraceptives, including
consultations, examinations, procedures, device insertion, ultrasound, anesthesia,
patient education, referrals, and counseling;
• Follow-up services related to contraceptive Drugs, devices, products, and
procedures, including but not limited to management of side effects, counseling
for continued adherence, and device removal;
• Voluntary tubal ligation and other similar sterilization procedures; and
• Vasectomy services and procedures.
Benefits do not include family planning services from Non-Participating Providers.
Family planning services may also be covered under the Preventive Health Services
Benefit and the Prescription Drug Benefit.
Fertility preservation services

Fertility preservation services are covered for Members undergoing treatment or
receiving Covered Services that may directly or indirectly cause iatrogenic Infertility.
Under these circumstances, standard fertility preservation services are a Covered
Service.
Home health services

Benefits are available for home health services. These services include home health
agency services, home infusion and injectable medication services, and hemophilia
home infusion services.
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Home health agency services

Benefits are available from a Participating home health care agency for diagnostic
and treatment services received in your home under a written treatment plan
approved by your Physician.
Benefits include:
• Intermittent home care for skilled services from:
o Registered nurses;
o Licensed vocational nurses;
o Physical therapists;
o Occupational therapists;
o Speech and language pathologists;
o Licensed clinical social workers; and
o Home Health Aides.
• Related medical supplies.
Intermittent home care is for skilled services you receive:
• Fewer than seven days per week; or
• Daily, for fewer than eight hours per day, up to 21 days.
Benefits are limited to a visit maximum as shown in the Summary of Benefits section
for home health agency visits. For this Benefit, coverage includes:
• Up to three visits per day, two hours maximum per visit, with a registered nurse,
licensed vocational nurse, physical therapist, occupational therapist, speech
and language pathologist, or licensed clinical social worker. A visit of two hours
or less is considered one visit. Nursing visits cannot be combined to provide
Continuous Nursing Services.
• Up to four hours maximum per visit with a Home Health Aide. A visit of four hours
or less is considered one visit.
• Continuous Nursing Services provided by a registered nurse or a licensed
vocational nurse, on a one-to-one basis, in an inpatient or home setting. These
services may also be described as “shift care” or “private duty nursing.”
Home infusion and injectable medication services

Benefits are available through a Participating home infusion agency for home
infusion, enteral, and injectable medication therapy.
Benefits include:
• Home infusion agency Skilled Nursing visits;
• Infusion therapy provided in an infusion suite associated with a Participating
home infusion agency;
• Administration of parenteral nutrition formulations and solutions;
• Administration of enteral nutrition formulas and solutions;
• Medical supplies used during a covered visit; and
• Medications injected or administered intravenously.
See the PKU formulas and special food products section for more information.
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There is no Calendar Year visit maximum for home infusion agency services.
This Benefit does not include:
• Insulin;
• Insulin syringes; and
• Services related to hemophilia, which are described below.
Hemophilia home infusion services

Benefits are available for hemophilia home infusion products and services for the
treatment of hemophilia and other bleeding disorders. Benefits must be prior
authorized and provided in the home or in an infusion suite managed by a
Participating Hemophilia Home Infusion Provider.
Benefits include:
• 24-hour service;
• Home delivery of hemophilia infusion products;
• Blood factor product;
• Supplies for the administration of blood factor product; and
• Nursing visits for training or administration of blood factor products.
There is no Calendar Year visit maximum for hemophilia home infusion agency
services.
• In-home services to treat complications of hemophilia replacement therapy; or
• Self-infusion training programs, other than nursing visits to assist in administration
of the product.
Most Participating home health care and home infusion agencies are not
Participating Hemophilia Home Infusion Providers. A list of Participating Hemophilia
Home Infusion Providers is available at blueshieldca.com.
Hospice program services

Benefits are available through a Participating Hospice Agency for specialized care if
you have been diagnosed with a terminal illness with a life expectancy of one year or
less. When you enroll in a Hospice program, you agree to receive all care for your
terminal illness through the Hospice Agency. Hospice program enrollment is prior
authorized for a specified period of care based on your Physician’s certification of
eligibility. The period of care begins the first day you receive Hospice services and ends
when the specified timeframe is over or you choose to receive care for your terminal
illness outside of the Hospice program.
The authorized period of care is for two 90-day periods followed by unlimited 60-day
periods, depending on your diagnosis. Your Hospice care continues through to the next
period of care when your Physician recertifies that you have a terminal illness. The
Hospice Agency works with your Physician to ensure that your Hospice enrollment
continues without interruption. You can change your Participating Hospice Agency only
once during each period of care.
A Hospice program provides interdisciplinary care designed to ease your physical,
emotional, social, and spiritual discomfort during the last phases of life, and support
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your primary caregiver and your family. Hospice services are available 24 hours a day
through the Hospice Agency.
While enrolled in a Hospice program, you may continue to receive Covered Services
that are not related to the care and management of your terminal illness from the
appropriate Health Care Provider. However, all care related to your terminal illness must
be provided through the Hospice Agency. You may discontinue your Hospice
enrollment when an acute Hospital admission is necessary, or at any other time. You
may also enroll in the Hospice program again when you are discharged from the
Hospital, or at any other time, with Physician recertification.
Benefits include:
• Pre-Hospice consultation to discuss care options and symptom management;
• Advance care planning;
• Skilled Nursing Services;
• Medical direction and a written treatment plan approved by a Physician;
• Continuous Nursing Services provided by registered or licensed vocational
nurses, eight to 24 hours per day;
• Home Health Aide services, supervised by a nurse;
• Homemaker services, supervised by a nurse, to help you maintain a safe and
healthy home environment;
• Medical social services;
• Dietary counseling;
• Volunteer services by a Hospice agency;
• Short-term inpatient, Hospice house, or Hospice care, if required;
• Drugs, medical equipment, and supplies;
• Physical therapy, occupational therapy, and speech-language pathology
services to control your symptoms or help your ability to perform Activities of Daily
Living;
• Respiratory therapy;
• Occasional, short-term inpatient respite care when necessary to relieve your
primary caregiver or family members, up to five days at a time;
• Bereavement services for your family; and
• Social services, counseling, and spiritual services for you and your family.
• Services provided by a Non-Participating Hospice Agency, except in certain
circumstances where there are no Participating Hospice Agencies in your area
and services are prior authorized.
Hospital services
Benefits are available for inpatient care in a Hospital.
Benefits include:
• Room and board, such as:
o Semiprivate Hospital room, or private room if Medically Necessary;
o Specialized care units, including adult intensive care, coronary care,
pediatric and neonatal intensive care, and subacute care;
o General and specialized nursing care; and
o Meals, including special diets.
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• Other inpatient Hospital services and supplies, including:

o Operating, recovery, labor and delivery, and other specialized treatment
rooms;
o Anesthesia, oxygen, medicines, and IV solutions;
o Clinical pathology, laboratory, radiology, and diagnostic services and
supplies;
o Dialysis services and supplies;
o Blood and blood products;
o Medical and surgical supplies, surgically implanted devices, prostheses, and
appliances;
o Radiation therapy, chemotherapy, and associated supplies;
o Therapy services, including physical, occupational, respiratory, and speech
therapy;
o Acute detoxification;
o Acute inpatient rehabilitative services; and
o Emergency room services resulting in admission.
Medical treatment of the teeth, gums, jaw joints, and jaw bones
Benefits are available for outpatient, Hospital, and professional services provided for
treatment of the jaw joints and jaw bones, including adjacent tissues.
Benefits include:
• Treatment of odontogenic and non-odontogenic oral tumors (benign or
malignant);
• Stabilization of natural teeth after traumatic injury independent of disease,
illness, or any other cause;
• Surgical treatment of temporomandibular joint syndrome (TMJ);
• Non-surgical treatment of TMJ;
• Orthognathic surgery to correct a skeletal deformity;
• Dental and orthodontic services directly related to cleft palate repair;
• Dental services to prepare the jaw for radiation therapy for the treatment of
head or neck cancers; and
• General anesthesia and associated facility charges during dental treatment
due to the Member’s underlying medical condition or clinical status when:
o The Member is younger than seven years old; or
o The Member is developmentally disabled; or
o The Member’s health is compromised and general anesthesia is
Medically Necessary.
• Diagnostic dental services such as oral examinations, oral pathology, oral
medicine, X-rays, and models of the teeth, except when related to surgical
and non-surgical treatment of TMJ;
• Preventive dental services such as cleanings, space maintainers, and habit
control devices except as covered under the Preventive Health Services
Benefit;
• Periodontal care such as hard and soft tissue biopsies and routine oral surgery
including removal of teeth;
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• Reconstructive or restorative dental services such as crowns, fillings, and root

canals;
• Orthodontia for any reason other than cleft palate repair;
• Dental implants for any reason other than cleft palate repair;
• Any procedure to prepare the mouth for dentures or for the more
comfortable use of dentures;
• Alveolar ridge surgery of the jaws if performed primarily to treat diseases
related to the teeth, gums, or periodontal structures, or to support natural or
prosthetic teeth; or
• Fluoride treatments for any reason other than preparation of the oral cavity
for radiation therapy or for Benefits covered under Preventive Health Services.
Mental Health and Substance Use Disorder Benefits

Blue Shield’s Mental Health Service Administrator (MHSA) administers Mental Health and
Substance Use Disorder services from MHSA Participating Providers for Members in
California. Blue Shield administers Mental Health and Substance Use Disorder services
from MHSA Non-Participating Providers for Members in California. See the Out-of-area
services section for an explanation of how Benefits are administered for out-of-state
services. Mental health services provided through Teladoc are administered by Blue
Shield, not the MHSA. See the Teladoc section for more information.
Mental Health and Substance Use Disorder Benefits include Medically Necessary basic
health care services and intermediate services, at the full range of levels of care,
including but not limited to residential treatment, Partial Hospitalization Program, and
Intensive Outpatient Program, and prescription Drugs.
The MHSA Participating Provider must get prior authorization from the MHSA for all non-
emergency Hospital admissions for Mental Health and Substance Use Disorder services,
and for certain outpatient Mental Health and Substance Use Disorder services. See the
Medical Management Programs section for more information about prior authorization.
The MHSA Participating Provider network is separate from Blue Shield’s Participating
Provider network. Visit blueshieldca.com and click on Find a Doctor to access the MHSA
Participating Provider network.
If you are unable to schedule an appointment with a Participating Provider for Mental
Health and Substance Use Disorder services, contact Mental Health Customer Service.
The MHSA will help you either schedule an appointment with a Participating Provider, or
select a Non-Participating Provider in your area within five calendar days and contact
you regarding available appointment times. For any Covered Services, you will be
responsible for no more than the Cost Share for seeing a Non-Participating Provider. The
MHSA may work with you to transition to a Participating Provider when one becomes
available.
Upon request to Mental Health Customer Service, and at no cost to you, Mental Health
Customer Service will provide the clinical review criteria and any training material or
resources used to conduct utilization reviews for Mental Health and Substance Use
Disorder benefits and services.
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Office visits
Benefits are available for professional office visits, including Physician office visits, for
the diagnosis and treatment of Mental Health and Substance Use Disorders in an
individual, Family, or group setting.
Benefits are also available for telebehavioral health online counseling services,
psychotherapy, and medication management with a mental health or substance
use disorder provider.
Other Outpatient Mental Health and Substance Use Disorder Services

In addition to office visits, Benefits are available for other outpatient services for the
diagnosis and treatment of Mental Health and Substance Use Disorders. You can
receive these other outpatient services in a facility, office, home, or other non-
institutional setting.
For Behavioral Health Crisis Services rendered by a Non-Participating Provider, you
will pay the same Cost Share for Covered Services received from a Participating
Provider. Prior authorization is not required for the Medically Necessary Treatment of
a Mental Health or Substance Use Disorder provided by a 988 center, Mobile Crisis
Team, or other Behavioral Health Crisis Services.
Other Outpatient Mental Health and Substance Use Disorder Services include, but
are not limited to:
• Behavioral Health Treatment – professional services and treatment programs,
including applied behavior analysis and evidence-based intervention programs,
prescribed by a Physician or licensed psychologist and provided under a
treatment plan approved by the MHSA to develop or restore, to the maximum
extent practicable, the functioning of an individual with pervasive
developmental disorder or autism;
• Behavioral Health Crisis Services and other services provided by a 988 center, a
Mobile Crisis Team, or other provider of Behavioral Health Crisis Services,
regardless of whether the service is rendered by a Participating or Non-
Participating Provider;
• Electroconvulsive therapy – the passing of a small electric current through the
brain to induce a seizure, used in the treatment of severe depression;
• Intensive Outpatient Program – outpatient care for mental health or substance
use disorders when your condition requires structure, monitoring, and
medical/psychological intervention at least three hours per day, three days per
week;
• Office-based opioid treatment – substance use disorder maintenance therapy,
including methadone maintenance treatment;
• Partial Hospitalization Program – an outpatient treatment program that may be
in a free-standing or Hospital-based facility and provides services at least five
hours per day, four days per week when you are admitted directly or transferred
from acute inpatient care following stabilization;
• Psychological Testing – testing to diagnose a mental health condition; and
• Transcranial magnetic stimulation – a non-invasive method of delivering
electrical stimulation to the brain for the treatment of severe depression.
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• Treatment for the purposes of providing respite, day care, or educational
services, or to reimburse a parent for participation in the treatment.
Inpatient Services
Benefits are available for inpatient facility and professional services for the treatment
of Mental Health and Substance Use Disorders in:
• A Hospital; or
• A free-standing residential treatment center that provides 24-hour care when
you do not require acute inpatient care.
Medically Necessary inpatient substance use disorder detoxification is covered
under the Hospital services Benefit.
Pediatric dental Benefits

Pediatric dental Benefits are available through the end of the month in which the
covered Member turns 19 years old. A contracted Dental Plan Administrator (DPA)
administers Blue Shield’s pediatric dental Benefits. The DPA’s network of DPA
Participating Providers renders Dental Care Services to Members. The DPA also serves as
the claims administrator for processing claims received from DPA Non-Participating
Providers.
If you have any questions about DPA Participating Providers or Benefits, visit
blueshieldca.com, use the Blue Shield mobile app, or contact dental customer service
at (800) 286-7401.
Pediatric dental Benefits covered by this plan are described in the pediatric dental
Benefits table at the end of this Agreement.
See the Pediatric dental exclusions and Pediatric dental limitations sections for
information on exclusions and limitations for your Pediatric dental Benefits.
DPA Participating Providers

The status of a DPA Participating Provider may change. To receive Benefits at the
DPA Participating Provider Cost Share, it is your responsibility to confirm that your
Dentist is a DPA Participating Provider before you access Covered Services. To
confirm that your Dentist is a DPA Participating Provider, visit blueshieldca.com, use
the Blue Shield mobile app, or contact dental customer service at (800) 286-7401.
DPA Non-Participating Providers

This plan allows you to access most pediatric dental Benefits from DPA Non-
Participating Providers. The Summary of Benefits section tells you which pediatric
dental Benefits can be obtained from DPA Non-Participating Providers.
Coordination of dental Benefits

This plan includes an embedded pediatric dental Benefit. For purposes of
coordinating Benefits, if you purchase a Family dental plan that includes a
supplemental pediatric dental plan, the embedded pediatric dental Benefits
covered under this plan will be paid first. For the purposes of coordinating Benefits,
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this medical plan is your primary pediatric dental Benefit plan and the Family
pediatric dental plan is the secondary pediatric dental Benefit plan.
Alternate Benefits provision

An alternate benefits provision allows a Benefit to be paid based on an alternate
procedure that is professionally acceptable and more cost-effective. This plan’s
alternate benefits provision is as follows: if dental standards indicate that a condition
can be treated by a less costly alternative to the service proposed by the attending
Dentist, the DPA will pay for Benefits based upon the less costly service. Any
difference in cost between the proposed service and the less costly alternative is
your financial responsibility.
Emergency Dental Conditions

Benefits are available for stabilization of an Emergency Dental Condition. Services for
an Emergency Dental Condition are covered at the Participating Provider Cost
Share, even if you receive treatment from a Non-Participating Provider. For the
lowest out-of-pocket expenses, you can go to a DPA Participating Provider for follow-
up dental care you need after your condition has stabilized.
Pediatric vision Benefits

Benefits are available for pediatric vision services from ophthalmologists, optometrists,
and opticians.
Pediatric vision Benefits are available through the end of the month in which the
covered Member turns 19 years old. A contracted Vison Plan Administrator (VPA)
administers Blue Shield’s pediatric vision Benefits. The VPA’s network of VPA Participating
Providers renders vision services to Members. The VPA also serves as the claims
administrator for processing claims received from VPA Participating Providers and Non-
Participating Providers.
If you have any questions about VPA Participating Providers or Benefits, visit
blueshieldca.com, use the Blue Shield mobile app, or contact vision customer service at
(855) 342-9105.
Benefits include:
• One comprehensive eye exam per Calendar Year. A comprehensive exam is a
general evaluation of the complete visual system. It includes a history, a general
medical observation, an external and ophthalmoscopic exam, an evaluation of
gross visual fields, a basic sensorimotor exam, and a refractive exam. If
indicated, it can include biomicroscopy, tonometry, or an exam for cycloplegia
or mydriasis. The presence of trauma, severe inflammation, or other
contraindication may prevent the provider from performing a complete exam.
Dilation is included if professionally indicated. The comprehensive exam may
occur in one session, or more than one if Medically Necessary.
o When you choose standard or non-standard contact lenses instead of
eyeglasses, you are eligible for contact lens fitting and evaluation services
once in a consecutive 12-month period by a VPA Participating Provider if
administered at the same time as the covered comprehensive examination
up to the Benefit Allowance with a maximum of two follow up visits. For non-
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standard specialty contact lenses (including, but not limited to, toric,
multifocal, and gas permeable lenses), you are responsible for the difference
between the amount Blue Shield pays and the amount billed by the VPA
• One of the following in a Calendar Year:
o One pair of eyeglass lenses which include choice of glass, plastic, or
polycarbonate lenses, all lens powers (single vision, bifocal, trifocal,
lenticular), fashion and gradient tinting, ultraviolet protective coating, and
oversized and glass-grey #3 prescription sunglass lenses (Note: Polycarbonate
lenses are covered in full for children, monocular patients, and patients with
prescriptions > +/- 6.00 diopters);
o Elective contact lenses that are chosen for cosmetic or convenience
purposes and are not Medically Necessary; or
o Non-elective (Medically Necessary) contact lenses prescribed following
cataract surgery, or when contact lenses are the only means to correct visual
acuity to 20/40 for keratoconus, 20/60 for anisometropia, or for certain
conditions of myopia (12 or more diopters), or hyperopia (7 or more diopters)
astigmatism (over 3 diopters). Contact lenses may also be Medically
Necessary in the treatment of the following conditions: pathological myopia,
aphakia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders,
and irregular astigmatism. A report from the provider and prior authorization
from the VPA is required.
• One eyeglass frame in a Calendar Year.
• Low Vision testing once in a consecutive five Calendar Year period. The need for
Low Vision testing is determined during a comprehensive eye exam. Low Vision
testing may be obtained only from a VPA Participating Provider specializing in
Low Vision care.
o A VPA Participating Provider may prescribe optical devices, such as high-
power eyeglasses, magnifiers, or telescopes, to maximize the remaining
usable vision. One optical device per Calendar Year is covered. A report
from the provider conducting the initial exam and prior authorization from the
VPA are required for both the exam and any prescribed optical device.
• Any eye exam required by the employer as a condition of employment.
• Orthoptics or vision training, subnormal vision aids, or non-prescription lenses for
glasses when no Vision Prescription Change is indicated.
• Replacement or repair of lost or broken lenses or frames, except as listed in this
Agreement.
• Medical or surgical treatment of the eyes, except as covered under the Hospital
services and Physician and other professional services Benefits.
VPA Participating Providers

The status of a VPA Participating Provider may change. To receive benefits at the
VPA Participating Provider Cost Share, it is your responsibility to confirm that your
provider is a VPA Participating Provider before you access Covered Services. To
confirm that your provider is a VPA Participating Provider, visit blueshieldca.com, use
the Blue Shield mobile app, or contact vision customer service at (855) 342-9105.
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VPA Non-Participating Providers

This plan allows you to access most pediatric vision Benefits from VPA Non-
Participating Providers. The Summary of Benefits section tells you which pediatric
vision Benefits can be obtained from VPA Non-Participating Providers.
Physician and other professional services

Benefits are available for services performed by a Physician, surgeon, or other Health
Care Provider to diagnose or treat a medical condition.
Benefits include:
• Office visits for examination, diagnosis, counseling, education, consultation, and
treatment;
• Specialist office visits;
• Urgent care center visits;
• Second medical opinions;
• Administration of injectable medications that must be administered by a Health
Care Provider;
• Administration of radiopharmaceutical medications;
• Outpatient services;
• Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment
center, or emergency room;
• Home visits;
• Telehealth consultations, provided remotely via communication technologies, for
examination, diagnosis, counseling, education, and treatment. Coverage for
these services will be on the same basis and to the same extent as a service
conducted in person; and
• Teladoc general medical consultations.
See the Mental Health and Substance Use Disorder Benefits section for information on
Mental Health and Substance Use Disorder office visits and Other Outpatient Mental
Health and Substance Use Disorder services.
PKU formulas and special food products

Benefits are available for formulas and special food products if you are diagnosed with
phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a
Physician or appropriately-licensed Health Care Provider.
Benefits include:
• Enteral formulas;
• Parenteral nutrition formulations; and
• Special food products for the dietary treatment of PKU.
• Grocery store foods including shakes, snack bars, used by the general
population;
• Additives such as thickeners, enzyme products; or
• Food that is naturally low in protein, unless specially formulated to have less than
one gram of protein per serving.
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Podiatric services
Benefits are available for the diagnosis and treatment of conditions of the foot, ankle,
and related structures. These services, including surgery, are generally provided by a
licensed doctor of podiatric medicine.
Pregnancy and maternity care

Benefits are available for maternity care services.
Benefits include:
• Prenatal care;
• Postnatal care;
• Involuntary complications of pregnancy;
• Inpatient Hospital services including labor, delivery, and postpartum care;
• Elective newborn circumcision within 18 months of birth; and
• Abortion and abortion-related services, including preabortion and followup
services.
See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive
Health Services sections for information about coverage of genetic testing and
diagnostic procedures related to pregnancy and maternity care.
The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a
minimum Hospital stay for the mother and newborn child of 48 hours after a normal,
vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation
with the mother, may determine that a shorter length of stay is adequate. If your
Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a
Health Care Provider whose scope of practice includes postpartum and newborn care.
This follow-up visit may occur at home or as an outpatient, as necessary. This visit will
include parent education, assistance and training in breast or bottle feeding, and any
necessary physical assessments for the mother and child. Prior authorization is not
required for this follow-up visit.
Prescription Drug Benefits

Benefits are available for outpatient prescription Drugs. Outpatient prescription Drugs
are self-administered Drugs approved by the U.S. Food and Drug Administration (FDA)
for sale to the public through retail or mail-order pharmacies that are prescribed and
are not provided for use on an inpatient basis. Drugs also include diabetic testing
supplies, self-applied continuous blood glucose monitors, and all related necessary
supplies.
A Physician or Health Care Provider must prescribe all Drugs covered under this Benefit,
including over-the-counter items. You must obtain all Drugs from a Participating
Pharmacy, except as noted below. Drugs, items, and services that are not covered
under this Benefit are listed in the Exclusions and limitations section.
Some Drugs, most Specialty Drugs, and prescriptions for Drugs exceeding specific
quantity limits require prior authorization to be covered. The prior authorization process
is described in the Prior authorization/exception request/step therapy process section.
You or your Physician may request prior authorization from Blue Shield.
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Prescription Drug information is available by logging into your member portal at

blueshieldca.com and selecting “Price Check My Rx.” This tool can show you:
• Your eligibility for a prescription Drug;
• The current cost of the prescription Drug;
• Any available lower cost alternative(s) to the prescription Drug based on your
plan Formulary and the pharmacy that fills your prescription;
• Any limits, restrictions, or requirements for each Drug, if applicable; and
• Your current plan Formulary.
“Price Check My Rx” prices are based on your Deductible and Out-of-Pocket Maximum
accruals (if applicable) at the time you view the prescription Drug price. Costs may be
different at the time you fill your prescription due to claims processing. You or your
Physician or Health Care Provider can also request this Prescription Drug information by
calling Customer Service.
Benefits are provided for COVID-19 therapeutics approved or granted emergency use
authorization by the U.S. Food and Drug Administration for treatment of COVID-19 when
prescribed or furnished by a Health Care Provider acting within their scope of practice
and the standard of care. Coverage is provided without a Cost Share for services
provided by a Participating Provider.
For a disease for which the Governor of the State of California has declared a public
health emergency, therapeutics approved or granted emergency use authorization by
the U.S. Food and Drug Administration for that disease will be covered without a Cost
Share.
Outpatient Drug Formulary

Blue Shield’s Drug Formulary is a list of FDA-approved Generic and Brand Drugs. This
list helps Physicians or Health Care Providers prescribe Medically Necessary and cost-
effective Drugs. Drugs not listed on the Formulary may be covered when approved
by Blue Shield through the exception request process.
Blue Shield’s Formulary is established and maintained by Blue Shield’s Pharmacy and
Therapeutics (P&T) Committee. This committee consists of Physicians and
pharmacists responsible for evaluating Drugs for relative safety, effectiveness,
evidence-based health benefit, and comparative cost. The committee also reviews
new Drugs, dosage forms, usage, and clinical data to update the Formulary four
times a year. Your Physician or Health Care Provider might prescribe a Drug even
though it is not included in the Blue Shield Formulary.
The Formulary is divided into Drug tiers. The tiers are described in the chart below.
Your Copayment or Coinsurance will vary based on the Drug tier. Drugs are placed
into tiers based on recommendations made by the P&T Committee.
Formulary Drug tiers
Drug Tier Description
Tier 1 • Most Generic Drugs and low-cost preferred Brand Drugs
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Formulary Drug tiers
Drug Tier Description

• Non-preferred Generic Drugs
Tier 2
• Preferred Brand Drugs
• Any other Drugs recommended by the P&T Committee
based on drug safety, efficacy, and cost
• Non-preferred Brand Drugs
Tier 3
• Drugs recommended by the P&T Committee based on drug
safety, efficacy, and cost
• Drugs that generally have a preferred and often less costly
therapeutic alternative at a lower tier
• Drugs that the FDA or drug manufacturer requires to be
Tier 4
distributed through Network Specialty Pharmacies
• Drugs that require you to have special training or clinical
monitoring
• Drugs that cost the plan more than $600 (net of rebates) for a
one-month supply
Visit blueshieldca.com/pharmacy, use the Blue Shield mobile

app, or contact Customer Service for more information on the
Drug Formulary or to request a printed copy of the Formulary.
Obtaining outpatient prescription Drugs at a Participating Pharmacy

You must present a Blue Shield ID card at a Participating Pharmacy to obtain
prescription Drugs. You can obtain prescription Drugs at any retail Participating
Pharmacy unless the Drug is a Specialty Drug. See the Obtaining Specialty Drugs
from a Network Specialty Pharmacy section for more information. If you obtain
Drugs at a Non-Participating Pharmacy, Blue Shield will deny the claim and will not
pay anything toward the cost of the Drugs, unless they are for a covered
emergency.
Visit blueshieldca.com/pharmacy or use the Blue Shield

mobile app to locate a retail Participating Pharmacy.
You must pay the applicable Copayment or Coinsurance for each prescription Drug
purchased from a Participating Pharmacy. When the Participating Pharmacy’s
contracted rate is less than your Copayment or Coinsurance, you only pay the
contracted rate. This amount will apply to any applicable Deductible and Out-of-
Pocket Maximum. Contraceptive Drugs and devices obtained from a Participating
Pharmacy are covered without a Copayment or Coinsurance, except for brands
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that have a generic equivalent. If your Physician or Health Care Provider determines
that the covered Generic Drug is not appropriate for you, the brand name
equivalent contraceptive will be covered without a Copayment or Coinsurance
upon submission of an exception request.
Drugs not listed on the Formulary may be covered if Blue Shield approves an
exception request. If an exception request is approved, Drugs that are categorized
as Tier 4 will be covered at the Tier 4 Copayment or Coinsurance. For all other Drugs
that are approved as an exception, the Tier 3 Copayment or Coinsurance applies. If
an exception is denied, the non-Formulary Drug is not covered and you are
responsible for the entire cost of the Drug.
If you, your Physician, or your Health Care Provider selects a Brand Drug when a
Generic Drug equivalent or Biosimilar Drug is available, you pay the difference in
cost, plus the applicable tier Copayment or Coinsurance of the Brand Drug. This is
calculated by taking the difference between the Participating Pharmacy’s
contracted rate for the Brand Drug and the Generic Drug equivalent or Biosimilar
Drug, plus the applicable tier Copayment or Coinsurance of the Brand Drug. For
example, you select Brand Drug A when there is an equivalent Generic Drug A or
Biosimilar Drug A available. The Participating Pharmacy’s contracted rate for Brand
Drug A is $300 and the contracted rate for Generic Drug A or Biosimilar Drug A is
$100. You would be responsible for paying the $200 difference in cost, plus the
applicable tier Copayment or Coinsurance of the Brand Drug. This difference in cost
does not apply to your Deductible or your Out-of-Pocket Maximum responsibility.
If you, your Physician, or your Health Care Provider believes the Brand Drug is
Medically Necessary, you can request an exception to the difference in cost
between the Brand Drug and Generic Drug equivalent or Biosimilar Drug through the
Blue Shield prior authorization process. The request will be reviewed for Medical
Necessity. If the request is approved, you will pay only the applicable tier
Copayment or Coinsurance for the Brand Drug.
See the Prior authorization/exception request/step therapy process section for more
information on the prior authorization process and exception requests.
Blue Shield created a Patient Review and Coordination (PRC) program to help
reduce harmful prescription drug misuse and the potential for abuse. Examples of
harmful misuse include obtaining an excessive number of prescription medications or
obtaining very high doses of prescription opioids from multiple providers or
pharmacies within a 90-day period. If Blue Shield determines a Member is using
prescription drugs in a potentially harmful, abusive manner, Blue Shield may, subject
to certain exemptions and upon 90 days’ advance notice, restrict a Member to
obtaining all non-emergent outpatient prescriptions drugs at a single pharmacy
home. This restriction applies for a 12-month period and may be renewed. The
pharmacy home, a single Participating Pharmacy, will be assigned by Blue Shield or
a Member may request to select a pharmacy home. Blue Shield may also require
prior authorization for all opioid medications if sufficient medical justification for their
use has not been provided. Members that disagree with their enrollment in the PRC
program can file an appeal or submit a grievance to Blue Shield as described in the
Grievance Process section. Members selected for participation in the PRC will
receive a brochure with full program details, including participation exemptions. Any
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interested Member can request a PRC program brochure by calling Customer

Service at the number listed on their Identification Card.
Obtaining outpatient prescription Drugs at a Non-Participating Pharmacy in

an emergency
When you receive Drugs from a Non-Participating pharmacy for a covered
emergency, you must pay for the prescription in full and then submit a claim form for
reimbursement. See the Claims section under Your payment information for more
information.
Obtaining outpatient prescription Drugs from the mail service pharmacy

You have an option to receive prescription Drugs from the mail service pharmacy
when you take maintenance Drugs on a regular basis to treat an ongoing chronic
condition. This allows you to receive up to a 90-day supply of the Drug, which may
save you money. You may enroll in this program online, by phone, or by mail. Once
enrolled, please allow up to 14 days to receive the Drug. If your Physician or Health
Care Provider submits a prescription for less than a 90-day supply, the mail service
pharmacy will only dispense the amount prescribed. Specialty Drugs are not
available from the mail service pharmacy.
You must pay the applicable Copayment or Coinsurance listed in the Summary of
Benefits for each prescription Drug.
Visit blueshieldca.com or use the Blue Shield mobile app for additional information
about how to get prescription Drugs from the mail service pharmacy.
Obtaining Specialty Drugs from a Network Specialty Pharmacy

Specialty Drugs are Drugs that require coordination of care, close monitoring, or
extensive patient training for self-administration that cannot be met by a retail
pharmacy, and that are available at a Network Specialty Pharmacy. Specialty Drugs
may also require special handling or manufacturing processes (such as
biotechnology), restriction to certain Physicians or pharmacies, or reporting of certain
clinical events to the FDA. Specialty Drugs generally have a higher cost.
Specialty Drugs are only available from a Network Specialty Pharmacy. If you obtain
a Specialty Drug anywhere other than at a Network Specialty Pharmacy, you may
be responsible for the entire cost of the Drug.
A Network Specialty Pharmacy provides Specialty Drugs by mail or, at your request,
will transfer the Specialty Drug to an associated retail store for pickup.
A Network Specialty Pharmacy offers 24-hour clinical services, coordination of care
with Physicians, and reporting of certain clinical events associated with select Drugs
to the FDA.
To be covered, most Specialty Drugs require prior authorization by Blue Shield, as
described in the Prior authorization/exception request/step therapy process section.
Drug manufacturers or other third parties may offer Drug discounts or copayment
assistance for certain Drugs. These types of programs can lower your out-of-pocket
costs. If you receive any discounts at a Network Specialty Pharmacy, only the
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amount you pay will be applied to any applicable Deductible and Out-of-Pocket
Maximum.
Visit blueshieldca.com for a complete list of Specialty Drugs or to select a Network
Specialty Pharmacy.
Prior authorization/exception request/step therapy process

Some Drugs and Drug quantities require approval based on Medical Necessity
before they are eligible for coverage under this Benefit. This process is prior
authorization.
The following Drugs require prior authorization:
• Some Formulary Drugs, preferred Drugs, non-preferred Drugs, compounded
drugs, and most Specialty Drugs;
• Drugs for the Medically Necessary treatment of Class III obesity when prior
authorized. You are required to enroll in a comprehensive weight loss program
that includes a reduced calorie diet, physical activity, and behavior therapy.
You will need to be in this type of program for a reasonable period of time, prior
to and while on the weight loss Drug;
• Drugs exceeding the maximum allowable quantity based on Medical Necessity
and appropriateness of therapy; and
• A Brand Drug, when a Generic Drug equivalent or Biosimilar Drug is available,
and you, your Physician, or your Health Care Provider is requesting coverage of
the Brand Drug without paying the difference in cost between the Brand Drug
and the Generic Drug equivalent or Biosimilar Drug. See the Obtaining
outpatient prescription Drugs at a Participating Pharmacy section for more
information about how a brand contraceptive may be covered without a
Copayment or Coinsurance.
You pay the Tier 3 Copayment or Coinsurance for covered compounded drugs.
You, your Physician, or your Health Care Provider may request prior authorization for
the Drugs listed above by submitting supporting information to Blue Shield. If the
request does not include all necessary supporting information, Blue Shield will notify
the requestor within 72 hours in routine circumstances or within 24 hours in exigent
circumstances. Once Blue Shield receives all required supporting information, Blue
Shield will provide prior authorization approval or denial within 72 hours of receipt in
routine circumstances or 24 hours in exigent circumstances. Exigent circumstances
exist when you have a health condition that may seriously jeopardize your life,
health, or ability to regain maximum function, or you are undergoing a current
course of treatment using a non-Formulary Drug.
To request coverage for a non-Formulary Drug, you, your representative, your
Physician, or your Health Care Provider may submit an exception request to Blue
Shield. You can submit an exception request by calling Customer Service. Once all
required supporting information is received, Blue Shield will approve or deny the
exception request, based on Medical Necessity, within 72 hours in routine
circumstances or 24 hours in exigent circumstances. See the Obtaining outpatient
prescription Drugs at a Participating Pharmacy section for more information about
how a brand contraceptive may be covered without a Copayment or Coinsurance.
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Step therapy is the process of beginning therapy for a medical condition with Drugs
considered first-line treatment or that are more cost-effective, then progressing to
Drugs that are the next line in treatment or that may be less cost-effective. Step
therapy requirements are based on how the FDA recommends that a Drug should
be used, nationally recognized treatment guidelines, medical studies, information
from the Drug manufacturer, and the relative cost of treatment for a condition. If
your Physician or Health Care Provider believes that step therapy coverage
requirements for a prescription need not be met and that the Drug is Medically
Necessary, the step therapy exception process must be used and timeframes
previously described (within 72 hours in routine circumstances or within 24 hours in
exigent circumstances) will also apply.
If Blue Shield denies a request for prior authorization or an exception request, you,
your representative, your Physician, or your Health Care Provider can file a grievance
with Blue Shield, as described in the Grievance process section.
Limitation on quantity of Drugs that may be obtained per prescription or refill

Except as otherwise stated in this section, you may receive up to a 30-day supply of
outpatient prescription Drugs. If a Drug is available only in supplies greater than 30
days, you must pay the applicable retail Copayment or Coinsurance for each
additional 30-day supply.
If you, your Physician, or your Health Care Provider request a partial fill of a Schedule
II Controlled Substance prescription, your Copayment or Coinsurance will be pro-
rated. The remaining balance of any partially filled prescription cannot be dispensed
more than 30 days from the date the prescription was written.
Blue Shield has a short cycle Specialty Drug program. With your agreement,
designated Specialty Drugs may be dispensed for a 15-day trial supply at a pro-rated
Copayment or Coinsurance for the initial prescription. This program allows you to
receive a 15-day supply of the Specialty Drug to help determine whether you will
tolerate it before you obtain the full 30-day supply. This program can help you save
money if you cannot tolerate the Specialty Drug. The Network Specialty Pharmacy
will contact you to discuss the advantages of the program, which you can elect at
that time. You, your Physician, or your Health Care Provider may choose a full 30-day
supply for the first fill.
If you agree to a 15-day trial, the Network Specialty Pharmacy will contact you prior
to dispensing the remaining 15-day supply to confirm that you are tolerating the
Specialty Drug.
Visit blueshieldca.com/pharmacy for a list of Specialty Drugs in

the short cycle Specialty Drug program.
You may receive up to a 90-day supply of Drugs from the mail service pharmacy. If
your Physician or Health Care Provider writes a prescription for less than a 90-day
supply, the mail service pharmacy will dispense that amount and you are responsible
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for the applicable mail service Copayment or Coinsurance listed in the Summary of
Benefits section. Refill authorizations cannot be combined to reach a 90-day supply.
Select over-the-counter drugs with a United States Preventive Services Task Force
(USPSTF) rating of A or B may be covered at a quantity greater than a 30-day supply.
You may receive up to a 12-month supply of hormonal contraceptive Drugs.
You may refill covered prescriptions at a Medically Necessary frequency.
Special programs
Blue Shield may offer programs to support the use of more cost-effective and
clinically appropriate prescription Drugs. Such programs may lower your out-of-
pocket cost for a limited time if you participate.
Preventive Health Services

Benefits are available for Preventive Health Services such as screenings, checkups, and
counseling to prevent health problems or detect them at an early stage. Blue Shield
only covers Preventive Health Services when you receive them from a Participating
Provider.
Benefits include:
• Evidence-based items, drugs, or services that have a rating of A or B in the
current recommendations of the United States Preventive Services Task Force
(USPSTF), such as:
o Screening for cancer, such as colorectal cancer, cervical cancer, breast
cancer, and prostate cancer;
o Screening for HPV;
o Screening for osteoporosis; and
o Health education;
• Immunizations recommended by either the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention, or the
most current version of the Recommended Childhood Immunization
Schedule/United States, jointly adopted by the American Academy of
Pediatrics, the Advisory Committee on Immunization Practices, and the
American Academy of Family Physicians;
• Evidence-informed preventive care and screenings for infants, children, and
adolescents as listed in the comprehensive guidelines supported by the Health
Resources and Services Administration, including screening for risk of lead
exposure and blood lead levels in children at risk for lead poisoning;
• Adverse Childhood Experiences screenings;
• California Prenatal Screening Program; and
• Additional preventive care and screenings for women not described above as
provided for in comprehensive guidelines supported by the Health Resources
and Services Administration. See the Family planning Benefits section for more
information.
If there is a new recommendation or guideline in any of the resources described above,
Blue Shield will have at least one year to implement coverage. The new
recommendation will be covered as a Preventive Health Service in the plan year that
begins after that year. However, for COVID-19 Preventive Health Services and
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Preventive Health Services for a disease for which the Governor of the State of
California has declared a public health emergency, a new recommendation will be
covered within 15 business days.
Visit blueshieldca.com/preventive for more information about

Preventive Health Services.
Reconstructive Surgery Benefits

Benefits are available for Reconstructive Surgery services.
Benefits include:
• Surgery to correct or repair abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma, infection, tumors, or
disease to:
o Improve function; or
o Create a normal appearance to the extent possible;
• Dental and orthodontic surgery services directly related to cleft palate repair;
and
• Surgery and surgically-implanted prosthetic devices in accordance with the
Women’s Health and Cancer Rights Act of 1998 (WHCRA).
• Cosmetic surgery, which is surgery that is performed to alter or reshape normal
structures of the body to improve appearance;
• Reconstructive Surgery when there is a more appropriate procedure that will be
approved; or
• Reconstructive Surgery to create a normal appearance when it offers only a
minimal improvement in appearance.
In accordance with the WHCRA, Reconstructive Surgery and surgically implanted and
non-surgically implanted prosthetic devices (including prosthetic bras) are covered for
either breast to restore and achieve symmetry following a mastectomy, and for the
treatment of the physical complications of a mastectomy, including lymphedemas. For
coverage of prosthetic devices following a mastectomy, see the Durable medical
equipment section. Medically Necessary services will be determined by your attending
Physician in consultation with you.
Benefits will be provided in accordance with guidelines established by Blue Shield and
developed in conjunction with plastic and reconstructive surgeons, except as required
under the WHCRA.
Rehabilitative and habilitative services

Benefits are available for outpatient rehabilitative and habilitative services.
Rehabilitative services help to restore the skills and functional ability you need to
perform Activities of Daily Living when you are disabled by injury or illness. Habilitative
services are therapies that help you learn, keep, or improve the skills or functioning you
need for Activities of Daily Living.
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These services include physical therapy, occupational therapy, and speech therapy.
Your Physician or Health Care Provider must prepare a treatment plan. Treatment must
be provided by an appropriately-licensed or certified Health Care Provider. You can
continue to receive rehabilitative or habilitative services as long as your treatment is
Medically Necessary.
Blue Shield may periodically review the provider’s treatment plan and records for
Medical Necessity.
See the Hospital services section for information about inpatient rehabilitative Benefits.
See the Home health services and Hospice program services sections for information
about coverage for rehabilitative and habilitative services provided in the home.
Physical therapy
Physical therapy uses physical agents and therapeutic treatment to develop,
improve, and maintain your musculoskeletal, neuromuscular, and respiratory systems.
Physical agents and therapeutic treatments include but are not limited to:
• Ultrasound;
• Heat;
• Range of motion testing;
• Targeted exercise; and
• Massage performed as part of a rehabilitative or habilitative physical therapy
treatment plan by a licensed or certified Health Care Provider.
Occupational therapy
Occupational therapy is treatment to develop, improve, and maintain the skills you
need for Activities of Daily Living, such as dressing, eating, and drinking.
Speech therapy
Speech therapy is used to develop, improve, and maintain vocal or swallowing skills
that have not developed according to established norms or have been impaired by
a diagnosed illness or injury. Benefits are available for outpatient speech therapy for
the treatment of:
• A communication impairment;
• A swallowing disorder;
• An expressive or receptive language disorder; and
• An abnormal delay in speech development.
Skilled Nursing Facility (SNF) services

Benefits are available for treatment in the Skilled Nursing unit of a Hospital or in a free-
standing Skilled Nursing Facility (SNF) when you are receiving Skilled Nursing or
rehabilitative services. This Benefit also includes care at the Subacute Care level.
Benefits must be prior authorized and are limited to a day maximum per benefit period,
as shown in the Summary of Benefits section. A benefit period begins on the date you
are admitted to the facility. A benefit period ends 60 days after you are discharged
from the facility or you stop receiving Skilled Nursing services. A new benefit period can
only begin after an existing benefit period ends.
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Transplant services
Benefits are available for tissue and kidney transplants and special transplants.
Tissue and kidney transplants

Benefits are available for facility and professional services provided in connection
with human tissue and kidney transplants when you are the transplant recipient.
Benefits include services incident to obtaining the human transplant material from a
living donor or a tissue/organ transplant bank.
Special transplants
Benefits are available for special transplants only if:
• The procedure is performed at a special transplant facility contracting with Blue
Shield, or if you access this Benefit outside of California, the procedure is
performed at a transplant facility designated by Blue Shield; and
• You are the recipient of the transplant.
Special transplants are:
• Human heart transplants;
• Human lung transplants;
• Human heart and lung transplants in combination;
• Human liver transplants;
• Human kidney and pancreas transplants in combination;
• Human bone marrow transplants, including autologous bone marrow
transplantation (ABMT) or autologous peripheral stem cell transplantation used to
support high-dose chemotherapy when such treatment is Medically Necessary
and is not Experimental or Investigational;
• Pediatric human small bowel transplants; and
• Pediatric and adult human small bowel and liver transplants in combination.
Donor services
Transplant Benefits include coverage for donation-related services for a living donor,
including a potential donor, or a transplant organ bank. Donor services must be
directly related to a covered transplant for a Member of this plan.
Donor services include:
• Donor evaluation;
• Harvesting of the organ, tissue, or bone marrow; and
• Treatment of medical complications for 90 days after the evaluation or harvest
procedure.
Urgent care services

Benefits are available for urgent care services you receive at an urgent care center or
during an after-hours office visit. You can access urgent care instead of going to the
emergency room if you have a medical condition that is not life-threatening but
prompt care is needed to prevent serious deterioration of your health.
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See the Out-of-area services section for information on urgent care services outside
California.
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Exclusions and limitations
This section describes the general exclusions and limitations that apply to all your plan
Benefits. Prescription Drug, pediatric dental, and pediatric vision Benefits each have
additional exclusions and limitations.
This section has the following tables:
• General exclusions and limitations (for all Benefits);
• Outpatient prescription Drug exclusions and limitations;
• Pediatric dental exclusions; and
• Pediatric dental limitations.
General exclusions and limitations
This plan only covers services that are Medically Necessary. A Physician or
1 other Health Care Provider’s decision to prescribe, order, recommend, or
approve a service or supply does not, in itself, make it Medically Necessary.
Routine physical examinations solely for:

• Immunizations and vaccinations, by any mode of administration, for the
2 purpose of travel; or
• Licensure, employment, insurance, court order, parole, or probation.
This exclusion does not apply to services deemed Medically Necessary
Treatment of a Mental Health or Substance Use Disorder.
Hospitalization solely for X-ray, laboratory or any other outpatient diagnostic

3
studies, or for medical observation.
Routine foot care items and services that are not Medically Necessary,
including:
• Callus treatment;
• Corn paring or excision;
4 • Toenail trimming;
• Over-the-counter shoe inserts or arch supports; or
• Any type of massage procedure on the foot.
This exclusion does not apply to items or services provided through a
Participating Hospice Agency or covered under the diabetes care Benefit.
Home services, hospitalization, or confinement in a health facility primarily for

rest, custodial care, or domiciliary care.
5
Custodial care is assistance with Activities of Daily Living furnished in the home
primarily for supervisory care or supportive services, or in a facility primarily to
provide room and board.
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Domiciliary care is a supervised living arrangement in a home-like environment
for adults who are unable to live alone because of age-related impairments or
physical, mental, or visual disabilities.
6 Continuous Nursing Services, private duty nursing, or nursing shift care, except
as provided through a Participating Hospice Agency.
Prescription and non-prescription oral food and nutritional supplements. This

exclusion does not apply to services listed in the Home infusion and injectable
7 medication services and PKU formulas and special food products sections, or
as provided through a Participating Hospice Agency. This exclusion does not
apply to services deemed Medically Necessary Treatment of a Mental Health
or Substance Use Disorder.
Hearing aids, hearing aid examinations for the appropriate type of hearing
aid, fitting, and hearing aid recheck appointments. The Hearing Aid Coverage
8 for Children Program (HACCP) offers state-funded hearing aid coverage to
eligible children and youth, ages 0-20. To learn more and apply, visit
www.dhcs.ca.gov/HACCP.
For Members 19 years of age and older: eye exams and refractions, lenses and
frames for eyeglasses, lens options, treatments, and contact lenses, except as
listed under the Prosthetic equipment and devices section.
9
For all Members: orthoptics or vision training except when Medically Necessary,
video-assisted visual aids or video magnification equipment for any purpose, or
surgery to correct refractive error.
Any type of communicator, voice enhancer, voice prosthesis, electronic voice

10 producing machine, or any other language assistive device. This exclusion
does not apply to items or services listed under the Prosthetic equipment and
devices section.
Dental services and supplies for treatment of the teeth, gums, and associated
periodontal structures, including but not limited to the treatment, prevention,
11 or relief of pain or dysfunction of the temporomandibular joint and muscles of
mastication. This exclusion does not apply to items or services provided under
the Medical treatment of the teeth, gums, or jaw joints and jaw bones,
Pediatric dental Benefits, and Hospital services sections.
Surgery that is performed to alter or reshape normal structures of the body to

12 improve appearance. This exclusion does not apply to Medically Necessary
treatment for complications resulting from cosmetic surgery, such as infections
or hemorrhages.
Any services related to assisted reproductive technology (including associated

13
services such as radiology, laboratory, medications, and procedures) including
but not limited to the harvesting or stimulation of the human ovum, in vitro
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fertilization, Gamete Intrafallopian Transfer (GIFT) procedure, Zygote
Intrafallopian Transfer (ZIFT), Intracytoplasmic sperm injection (ICSI), pre-
implantation genetic screening, donor services or procurement and storage of
donor embryos, oocytes, ovarian tissue, or sperm, any type of artificial
insemination, services or medications to treat low sperm count, or services
incident to reversal of surgical sterilization, except for Medically Necessary
treatment of medical complications of the reversal procedure.
Services for anyone in connection with a Surrogacy Arrangement, except for

14 Covered Services provided to a Member who is a surrogate. For more
information, see the Reductions – Surrogacy Arrangement section.
Home testing devices and monitoring equipment. This exclusion does not
15 apply to COVID-19 at-home testing kits, sexually transmitted disease home
testing kits, or items specifically described in the Durable medical equipment or
Diabetes care services sections.
16 Preventive Health Services performed by a Non-Participating Provider, except

laboratory services under the California Prenatal Screening Program.
Services performed in a Hospital by house officers, residents, interns, or other

17 professionals in training without the supervision of an attending Physician in
association with an accredited clinical education program.
18 Services performed by your spouse, Domestic Partner, child, brother, sister, or

parent.
Services provided by an individual or entity that:

• Is not appropriately licensed or certified by the state to provide health
care services;
• Is not operating within the scope of such license or certification; or
• Does not maintain the Clinical Laboratory Improvement Amendments
19 certificate required to perform laboratory testing services.
This exclusion does not apply to Behavioral Health Treatment Benefits listed
under the Mental Health and Substance Use Disorder Benefits section or to
services deemed Medically Necessary Treatment of a Mental Health or
Substance Use Disorder provided by an individual trainee, associate or
applicant for licensure who is supervised as required by applicable law.
Select physical and occupational therapies, such as:

• Massage therapy, unless it is performed as part of a rehabilitative or
20 habilitative physical therapy treatment plan by a licensed or certified
Health Care Provider. Massage is considered not Medically Necessary
when performed as the solitary treatment or prescribed to an individual
who presents with no complications;
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• Training or therapy for the treatment of learning disabilities or behavioral
problems;
• Social skills training or therapy;
• Vocational, educational, recreational, art, dance, music, or reading
therapy; and
• Testing for intelligence or learning disabilities.
This exclusion does not apply to services deemed Medically Necessary
Treatment of a Mental Health or Substance Use Disorder.
Weight control programs and exercise programs. This exclusion does not apply
21 to nutritional counseling provided under the Diabetes care services section, or
to services deemed Medically Necessary Treatment of a Mental Health or
Substance Use Disorder, or Preventive Health Services.
22 Services or Drugs that are Experimental or Investigational in nature.
Services that cannot be lawfully marketed without approval of the U.S. Food
and Drug Administration (FDA), including, but not limited to:
• Drugs;
• Medicines;
• Supplements;
• Tests;
23 • Vaccines;
• Devices; and
• Radioactive material.
However, drugs and medicines that have received FDA approval for
marketing for one or more uses will not be denied on the basis that they are
being prescribed for an off-label use if the conditions set forth in California
Health & Safety Code Section 1367.21 have been met.
The following non-prescription (over-the-counter) medical equipment or

supplies:
24
• Oxygen saturation monitors;
• Prophylactic knee braces; and
• Bath chairs.
25 Member convenience items or services, such as internet, phones, televisions,

guest trays, personal hygiene items, and food delivery services.
Disposable supplies for home use except as provided under the Durable
26 medical equipment, Home health services, and Hospice program services
sections, or the Prescription Drug Benefit.
27 Services incident to any injury or disease arising out of, or in the course of,
employment for salary, wage, or profit if such injury or disease is covered by
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any workers’ compensation law, occupational disease law, or similar
legislation. However, if Blue Shield provides payment for such services, we will
be entitled to establish a lien up to the amount paid by Blue Shield for the
treatment of such injury or disease.
28 Chiropractic spinal manipulation and adjustment.
Transportation by car, taxi, bus, gurney van, wheelchair van, and any other
29 type of transportation (other than a licensed ambulance or psychiatric
transport van).
30 Drugs dispensed by a Physician or Physician’s office for outpatient use.
31 Hospital care programs or services provided in a home setting (Hospital-at-

home programs).
Outpatient prescription Drug exclusions and limitations

Drugs packaged in convenience kits that include non-prescription convenience
1 items, unless the Drug is not otherwise available without the non-prescription
convenience items. This exclusion will not apply to items used for the
administration of diabetes or asthma Drugs.
2 Drugs when prescribed for cosmetic purposes. This includes, but is not limited to,
Drugs used to slow or reverse the effects of skin aging or to treat hair loss.
Medical devices or supplies, except as listed in the Durable medical equipment

3 section. This exclusion also applies to prescription preparations applied to the
skin that are approved by the FDA as medical devices.
4 Non-Formulary Drugs, unless an exception request is approved. See the

Prescription Drug Benefits section for more information.
5 Drugs obtained from a Non-Participating Pharmacy. This exclusion does not

apply to Drugs obtained on an emergency basis.
6 Drugs obtained from a pharmacy that is not licensed by the State Board of
Pharmacy, or included on a government exclusion list.
Drugs that are available without a prescription (over-the-counter), including

drugs for which there is an over-the-counter drug that has the same active
7 ingredient and dosage as the prescription Drug. This exclusion will not apply to
over-the-counter drugs with a United States Preventive Services Task Force
(USPSTF) rating of A or B when prescribed by a Physician or to over-the-counter
contraceptive Drugs and devices.
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8 Prescription Drugs that are repackaged by an entity other than the original
manufacturer.
9 Replacement of lost, stolen, or destroyed Drugs.
10 Immunizations and vaccinations solely for the purpose of travel.
Compounded medications unless all of the following requirements are met:

• A compounded medication includes at least one Drug;
• The compounded medication does not contain a bulk chemical (except
11 for bulk chemicals that meet FDA criteria for use as part of a Medically
Necessary compound);
• There are no FDA-approved, commercially-available, medically-
appropriate alternatives; and
• The compounded medication is self-administered.
A manufacturer’s product may be excluded when the same or similar Drug (one
with the same active ingredient or same therapeutic effect) is available under
12 this Prescription Drug Benefit. Any dosage or formulation of a Drug may be
excluded when the same Drug is available under the Prescription Drug Benefit
in a different dosage or formulation.
Drugs for weight loss when prescribed solely for the purpose of losing weight,
13 except for Medically Necessary treatment of Class III obesity when prior
authorized. This exclusion does not apply to items or services deemed Medically
Necessary Treatment of a Mental Health or Substance Use Disorder.
Pediatric dental exclusions
Additional treatment costs incurred because a dental procedure is unable to

1 be performed in the Dentist’s office due to the general health and physical
limitations of the Member.
General anesthesia or intravenous/conscious sedation unless specifically listed

2 as a Benefit in the Summary of Benefits section or on the pediatric dental
Benefits table, or administered by a Dentist for a covered oral surgery.
3 Cosmetic dental care.
Treatment for which payment is made by any governmental agency, including

4
any foreign government.
Services of Dentists or other practitioners of healing arts not associated with the
5 plan, except upon referral arranged by a Dental Provider and authorized by
the DPA, or when required in a covered emergency.
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6 Hospital charges of any kind.
Procedures, appliances, or restorations to correct congenital or developmental

7 malformations, unless specifically listed in the Summary of Benefits section or on
the pediatric dental Benefits table.
8 Malignancies.
9 Drugs not normally supplied in a dental office.
Dental Care Services administered by a pediatric Dentist, except when:
10 • The Member child’s primary Dental Provider is a pediatric Dentist; or

• The Member child is referred to a pediatric Dentist by the primary Dental
Provider.
11 The cost of precious metals used in any form of dental Benefits.
12 Loss or theft of dentures or bridgework.
13 Charges for second opinions, unless previously authorized by the DPA.
Pediatric dental limitations

• Fluoride treatment (D1206 and D1208) is only a Benefit for
prescription-strength fluoride products;
• Fluoride treatments do not include treatments that use
Preventive fluoride with prophylaxis paste or the topical application of
(D1000- fluoride to the prepared portion of a tooth prior to restoration
D1999) and applications of aqueous sodium fluoride; and
• The application of fluoride is only a Benefit for caries control
and is reimbursed when covered as a full mouth treatment
regardless of the number of teeth treated.
• Restorative services provided solely to replace tooth structure

lost due to attrition, abrasion, erosion, or for cosmetic
purposes;
• Restorative services when the prognosis of the tooth is
Restorative questionable due to non-restorability or periodontal
involvement;
(D2000- • Restorations for primary teeth near exfoliation;
D2999) • Replacement of otherwise satisfactory amalgam restorations
with resin-based composite restorations, unless a specific
allergy has been documented by a medical specialist
(allergist) on his or her professional letterhead or prescription;
• Prefabricated crowns for primary teeth near exfoliation;
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• Prefabricated crowns for abutment teeth for cast metal
framework partial dentures (D5213 and D5214);
• Prefabricated crowns provided solely to replace tooth
structure lost due to attrition, abrasion, erosion, or for cosmetic
purposes;
• Prefabricated crowns when the prognosis of the tooth is
questionable due to non-restorability or periodontal
involvement;
• Prefabricated crowns when a tooth can be restored with an
amalgam or resin-based composite restoration;
• Restorative services provided solely to replace tooth structure
lost due to attrition, abrasion, erosion, or for cosmetic
purposes;
• Laboratory crowns when the prognosis of the tooth is
involvement; and
• Laboratory processed crowns when the tooth can be
restored with an amalgam or resin-based composite.
• Endodontic procedures when the prognosis of the tooth is

involvement;
• Endodontic procedures when extraction is appropriate for a
Endodontic tooth due to non-restorability, periodontal involvement, or for
(D3000- a tooth that is easily replaced by an addition to an existing or
D3999) proposed prosthesis in the same arch; and
• Endodontic procedures for third molars, unless the third molar
occupies the first or second molar positions or is an abutment
for an existing fixed or removable partial denture with cast
clasps or rests.
• Tooth-bounded spaces shall only be counted in conjunction

Periodontal with osseous surgeries (D4260 and D4261) that require a
(D4000- surgical flap. Each tooth-bounded space shall only count as
D4999) one tooth space regardless of the number of missing natural
teeth in the space.
• Prosthodontic services provided solely for cosmetic purposes;

• Temporary or interim dentures to be used while a permanent
denture is being constructed;
• Spare or backup dentures;
Prosthodontic • Evaluation of a denture on a maintenance basis;
(D5000- • Preventative, endodontic, or restorative procedures for teeth
D5899) to be retained for overdentures. Only extractions for the
retained teeth are covered;
• Partial dentures to replace missing third molars;
• Laboratory relines (D5760 and D5761) for resin-based partial
dentures (D5211and D5212);
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• Laboratory relines (D5750, D5751, D5760, and D5761) within 12
months of chairside relines (D5730, D5731, D5740, and D5741);
• Chairside relines (D5730, D5731, D5740, and D5741) within 12
months of laboratory relines (D5750, D5751, D5760, and
D5761);
• Tissue conditioning (D5850 and D5851) is only covered to heal
unhealthy ridges prior to a definitive prosthodontic treatment;
and
• Tissue conditioning (D5850 and D5851) is covered the same
date of service as an immediate prosthesis that required
extractions.
Implant • Implant services are covered only when exceptional medical

conditions are documented and the services are considered
(D6000- Medically Necessary. Single tooth implants are not a Benefit.
D6199)
• Fixed partial dentures (bridgework); however, the fabrication

of a fixed partial denture shall be considered when medical
conditions or employment preclude the use of a removable
partial denture;
Prosthodontic • Fixed partial dentures when the prognosis of the retainer
(Fixed) (abutment) teeth is questionable due to non-restorability or
periodontal involvement;
(D6200- • Posterior fixed partial dentures when the number of missing
D6999) teeth requested to be replaced in the quadrant does not
significantly impact masticatory ability;
• Fixed partial denture inlay/onlay retainers (abutments)
(D6545-D6634); and
• Cast resin bonded fixed partial dentures (Maryland Bridges).
• The prophylactic extraction of third molars;

• Temporomandibular joint (TMJ) dysfunction procedures are
Oral and limited to differential diagnosis and symptomatic care. TMJ
Maxillofacial treatment modalities that involve prosthodontics,
Surgery orthodontics, and full or partial occlusal rehabilitation are not
covered;
(D7000- • TMJ dysfunction procedures solely for the treatment of
D7999) bruxism; and
• Suture procedures (D7910, D7911 and D7912) for the closure
of surgical incisions.
Orthodontic procedures are covered when Medically Necessary to

treat handicapping malocclusion, cleft palate, or facial growth
management cases for Members under the age of 19, when prior
Orthodontic
authorization is obtained.
Medically Necessary orthodontic treatment is limited to the following
instances related to an identifiable medical condition. An initial
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orthodontic exam (D0140), called the Limited Oral Evaluation, must
be conducted. This exam includes completion and submission of the
completed Handicapping Labio-Lingual Deviation (HLD) Score Sheet
with the Specialty Referral Request Form. The HLD Score Sheet is the
preliminary measurement tool used in determining if the Member
qualifies for Medically Necessary orthodontic services.
Orthodontic procedures are covered only when the diagnostic casts
verify a minimum score of 26 points on the HLD Index California
Modification Score Sheet Form, DC016 (06/09), one of the six
automatic qualifying conditions below exist; or when there is written
documentation of a craniofacial anomaly from a credentialed
specialist on his or her professional letterhead.
The immediate qualifying conditions are:
• Cleft lip and or palate deformities;
• Craniofacial Anomalies including the following:
o Crouzon’s syndrome;
o Treacher-Collins syndrome;
o Pierre-Robin syndrome; and
o Hemi-facial atrophy, Hemi-facial hypertrophy and other
severe craniofacial deformities that result in a physically
handicapping malocclusion as determined by our dental
consultants;
• Deep impinging overbite, where the lower incisors are
destroying the soft tissue of the palate and tissue laceration
and/or clinical attachment loss are present. (Contact only
does not constitute deep impinging overbite.);
• Crossbite of individual anterior teeth when clinical
attachment loss and recession of the gingival margin are
present, such as stripping of the labial gingival tissue on the
lower incisors. Treatment of bi-lateral posterior crossbite is not
covered;
• Severe traumatic deviation must be justified by attaching a
description of the condition; and
• Overjet greater than 9mm or mandibular protrusion (reverse
overjet) greater than 3.5mm.
The remaining conditions must score 26 or more to qualify (based on
the HDL Index).
• Coverage for the following conditions is excluded:
o Crowded dentitions (crooked teeth);
o Excessive spacing between teeth;
o Temporomandibular joint (TMJ) conditions and/or
horizontal/vertical (overjet/overbite) discrepancies;
o Treatment in progress prior to the effective date of
coverage;
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o Extractions required for orthodontic purposes;
o Surgical orthodontics or jaw repositioning;
o Myofunctional therapy;
o Macroglossia;
o Hormonal imbalances;
o Orthodontic retreatment when initial treatment was
rendered under this plan or changes in orthodontic
treatment necessitated by any kind of accident;
o Palatal expansion appliances;
o Services performed by outside laboratories; and
o Replacement or repair of lost, stolen or broken appliances
damaged due to the neglect of the Member.
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95
Grievance process
Blue Shield has a formal grievance process to address any complaints, disputes,
requests for reconsideration of health care coverage decisions made by Blue Shield, or
concerns with the quality of care you received from a provider. Blue Shield will receive,
review, and resolve your grievance within the required timeframes.
Submitting a grievance
If you have a question about your Benefits or any action taken by Blue Shield (or a
Benefit Administrator), your first step is to make an inquiry through Customer Service. If
Customer Service is not able to fully address your concerns, you can then submit a
grievance or ask the Customer Service representative to submit one for you. If Blue
Shield denies authorization or coverage for health care services, you can appeal the
denial and Blue Shield will reconsider your request.
You have 180 days after a denial or other incident to submit your grievance to Blue
Shield. Your provider, or someone you choose to represent you, can also submit a
grievance on your behalf.
The fastest way to submit a grievance is online at blueshieldca.com. You can also
submit the form by mail or begin the grievance process by calling Customer Service.
Where to mail grievances
Type of grievance Address
Medical and prescription Drug Benefits Blue Shield of California

Customer Service Appeals and Grievance
P.O. Box 5588
El Dorado Hills, CA 95762
Mental Health and Substance Use Disorder Blue Shield of California

services from an MHSA Participating Mental Health Service Administrator
Provider P.O. Box 719002
San Diego, CA 92171
Mental Health and Substance Use Disorder Blue Shield of California

services from an MHSA Non-Participating Customer Service Appeals and Grievance
Provider P.O. Box 5588
El Dorado Hills, CA 95762
Pediatric dental Benefits Blue Shield of California

Dental Plan Administrator
Attn: Dental Appeals/Grievances
P.O. Box 30545
Salt Lake City, UT 84130-0545
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Grievance process 96
Where to mail grievances
Type of grievance Address
Pediatric vision Benefits Blue Shield of California

Vision Plan Administrator
Attn: Quality Assurance
4000 Luxottica Place
Cincinnati, OH 45040
Once Blue Shield or the MHSA receives your grievance, they will send a written
acknowledgment within five calendar days.
Blue Shield will resolve your grievance and provide a written response within 30
calendar days. The response will explain what action you can take if you are not
satisfied with how your grievance is resolved.
If Blue Shield denies an exception request for coverage of a non-Formulary Drug or step
therapy, you may request an external exception request review. Blue Shield will ensure
a decision within 72 hours. Blue Shield will make a decision within 24 hours when there
are exigent circumstances related to denial of an exception request for a non-
Formulary Drug or step therapy.
Expedited grievance request

You can submit an expedited grievance request to Blue Shield when the routine
grievance process might seriously jeopardize your life, health, or recovery, or when
you are experiencing severe pain.
Blue Shield will make a decision within three calendar days for expedited grievance
requests related to:
• Medical Benefits;
• Mental Health and Substance Use Disorder services;
• Pediatric dental Benefits; and
• Pediatric vision Benefits.
Once a decision is made, Blue Shield will notify you and your provider as soon as
possible to accommodate your condition.
California Department of Managed Health Care review

The California Department of Managed Health Care is responsible for regulating health
care service plans. If you have a grievance against your health plan, you should first
telephone your health plan at (855) 836-9705 and use your health plan’s grievance
process before contacting the Department. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be available to you. If you need
help with a grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has remained unresolved
for more than 30 days, you may call the Department for assistance. You may also be
eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR
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Grievance process 97
process will provide an impartial review of medical decisions made by a health plan
related to the Medical Necessity of a proposed service or treatment, coverage
decisions for treatments that are Experimental or Investigational in nature, and payment
disputes for emergency or urgent medical services. The Department also has a toll-free
telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing
and speech impaired. The Department’s internet website (www.dmhc.ca.gov) has
complaint forms, IMR application forms, and instructions online.
If you feel Blue Shield improperly cancels, rescinds, or does not renew coverage for you
or your Dependents, you can submit a request for review to Blue Shield or to the
Director of the California Department of Managed Health Care. Any request for review
submitted to Blue Shield will be treated as an expedited grievance.
Independent medical review

You may be eligible for an independent medical review if your grievance involves a
claim or service for which coverage was denied on the grounds that the service is:
• Not Medically Necessary; or
• Experimental or Investigational (including the external review available under the
Friedman-Knowles Experimental Treatment Act of 1996).
You can apply to the Department of Managed Health Care (DMHC) for an
independent medical review of the denial. For a Medical Necessity denial, you must
first submit a grievance to Blue Shield and wait for at least 30 days before requesting an
independent medical review. However, if the request qualifies for an expedited review
as described above, or if it involves a determination that the requested service is
Experimental or Investigational, you may request an independent medical review as
soon as you receive a notice of denial from Blue Shield. The DMHC’s application for
independent medical review is included with your appeal outcome letter.
The DMHC will review your application. If the request qualifies for independent medical
review, the DMHC will select an independent review organization to conduct a clinical
review of your medical records. You can submit additional records for consideration as
well. There is no cost to you for this independent medical review. You and your provider
will receive copies of the independent medical review determination. The decision of
the independent review organization is binding on Blue Shield. If the reviewer
determines that the requested service is clinically appropriate, Blue Shield will arrange
for the service to be provided or the disputed claim to be paid.
The independent medical review process is in addition to any other procedures or
remedies available to you to resolve coverage disputes. It is completely voluntary. You
are not required to participate in the independent medical review process, but if you
do not, you may lose your statutory right to pursue legal action against Blue Shield
regarding the disputed service.
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98
Other important information about your plan
This section provides legal and regulatory details that impact your health care
coverage. This information is a supplement to the information provided in earlier
sections of this document and is part of the contractual agreement between the
Subscriber and Blue Shield.
Your coverage, continued

Special enrollment period
For more information about special enrollment periods, see

Special enrollment period on page 46 in the Your coverage
section.
A special enrollment period is a timeframe outside of open enrollment when a

Qualified Individual can enroll in, or change enrollment in, a health plan. The special
enrollment period is 60 days following the date of a Triggering Event, unless a
different period is specified below. When the loss of minimum essential coverage is
anticipated, a special enrollment period also precedes the Triggering Event. The
following are Triggering Events:
• Loss of minimum essential coverage for a reason other than:
o Failure to pay premiums on a timely basis (including Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA) or Cal-COBRA
premiums);
o A situation that would allow a rescission, such as an intentional
misrepresentation of a material fact on the application for coverage; or
o Other loss of coverage due to the fault of the enrollee. Additional 60-day
period before Triggering Event applies.
• Loss or anticipated loss of coverage under an employer-sponsored health plan
as a result of:
o With respect to the Subscriber:
▪ The termination of employment (other than through gross misconduct);
or
▪ The reduction of hours of employment to less than the number of hours
required for eligibility.
o With respect to the spouse, Domestic Partner and Dependent children:
▪ The death of the Subscriber;
▪ The termination of the Subscriber’s employment (other than through
the Subscriber’s gross misconduct);
▪ The reduction of the Subscriber’s hours of employment to less than the
number of hours required for eligibility;
▪ The divorce or legal separation of the Subscriber from the Dependent
spouse or termination of the domestic partnership;
▪ The Subscriber’s entitlement to benefits under Title XVIII of the Social
Security Act (“Medicare”);
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Other important information about your plan 99
▪ A Dependent child’s loss of Dependent status under the generally

applicable requirements of the plan; or
▪ The employer files for reorganization under Title XI of the United States
Code, commencing on or after July 1, 1986 (COBRA only - when the
Subscriber is covered as a retiree).
o Discontinuation of the employer’s contribution toward Subscriber or
Dependent coverage.
o Exhaustion of COBRA or Cal-COBRA continuation coverage or complete
loss of employer premium contributions or governmental subsidies.
• Loss of Medi-Cal coverage for pregnancy-related services or loss of access to
CHIP unborn child coverage due to the birth of the child. The special enrollment
period begins 60 days before the Triggering Event and ends 90 days after the
Triggering Event.
• Loss of Medi-Cal medically needy coverage (only once per calendar year). The
special enrollment period begins 60 days before the Triggering Event and ends
90 days after the Triggering Event.
• Acquiring or becoming a Dependent through marriage, establishment of
domestic partnership, becoming a qualifying parent or stepparent, birth,
adoption, placement for adoption, placement in foster care or through a child
support order or other court order.
o If a parent is required to provide health insurance coverage for a child,
and enrollment is requested by the Subscriber parent or upon
presentation of a court order or request by the non-Subscriber parent, the
local child support agency, or person having custody of the child, or the
Medi–Cal program.
• A Qualified Individual’s or Dependent’s enrollment or non-enrollment in a health
plan is unintentional, inadvertent, or erroneous and is the result of the error,
misrepresentation, or inaction of an officer, employee, or agent of Blue Shield,
Covered California, or the Department of Health and Human Services (HHS),
evaluated and determined by Covered California. In such cases the action may
be taken to correct or eliminate the effects of such error, misrepresentation, or
inaction.
• A Qualified Individual or Dependent demonstrates that they did not enroll in a
health plan during the immediately preceding enrollment period available to
the individual because they were misinformed that they were covered under
minimum essential coverage.
• A Qualified Individual or Dependent demonstrates that the health plan in which
they are enrolled substantially violated a material provision of its contract in
relation to the Qualified Individual or Dependent.
• A Qualified Individual or Dependent gains access to a new health plans as a
result of a permanent move.
• A Qualified Individual or Dependent is determined newly eligible for advance
payments of the premium tax credit or for cost-sharing reductions. Additional 60-
day period before Triggering Event applies.
• A Qualified Individual or Dependent is determined newly ineligible for advance
payments of the premium tax credit or for cost-sharing reductions.
• A Qualified Individual or Dependent has been released from incarceration.
• A Qualified Individual is a victim of domestic abuse or spousal abandonment, is
enrolled in minimum essential coverage, and seeks to enroll in coverage
separate from the perpetrator of the abuse or abandonment. A Dependent of a
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victim of domestic abuse or spousal abandonment who is on the same

application as the victim may enroll in coverage at the same time as the victim.
• A Qualified Individual or Dependent:
o Applies for coverage from Covered California during the annual open
enrollment period or due to a Triggering Event, is assessed by the
exchange as potentially eligible for Medi-Cal, and is determined ineligible
for Medi-Cal either after open enrollment has ended or more than 60 days
after the Triggering Event; or
o Applies for Medi-Cal during the annual open enrollment period, and is
determined ineligible after open enrollment has ended.
• A Qualified Individual or Dependent was receiving services from a contracting
provider under another health plan for one of the conditions eligible for
completion of Covered Services and that provider is no longer participating in
the other health plan.
• A Qualified Individual or Dependent is a member of the reserve forces of the
United States military returning from active duty or a member of the California
National Guard returning from active duty service under Title 32 of the United
States Code.
• A Qualified Individual or Dependent is enrolled in an eligible employer-sponsored
plan that will no longer be affordable or provide minimum value.
• A Qualified Individual or Dependent gains access to and enrolls in a qualified
small employer health reimbursement arrangement (QSEHRA) or an individual
coverage health reimbursement arrangement (ICHRA).
o The special enrollment period is 60 days before the Triggering Event if the
Qualified Individual receives a written notice of eligibility from the QSHRA
or ICHRA at least 90 days before the beginning of the QSHRA or ICHRA
plan year.
o The special enrollment period is 60 days before or after the Triggering
Event if the Qualified Individual does not receive a written notice of
eligibility from the QSEHRA or ICHRA at least 90 days before the beginning
of the QSHRA or ICHRA plan year.
• A Qualified Individual or Dependent is enrolled in a Qualified Health Plan that is
decertified.
• An individual or Dependent is deemed a Qualified Individual because he or she
is no longer incarcerated or considered a non-resident.
• A Qualified Individual or Dependent demonstrates to the exchange, in
accordance with HHS guidelines, that the individual meets other exceptional
circumstances as the exchange may allow.
• In the case of coverage offered through an HMO, or other network
arrangement, that does not provide benefits to individuals who no longer reside,
live, or work in a service area.
o Individual plan: loss of coverage because the individual no longer resides,
lives, or works in the service area (whether or not within the choice of the
individual).
o Group plan: loss of coverage because the individual no longer resides,
lives, or works in the service area (whether or not within the choice of the
individual and no other benefit package is available to the individual).
• A situation in which a Qualified Health Plan no longer offers any benefits to the
class of similarly situated individuals that includes the individual.
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• National public health emergency or pandemic that results in a declaration of

state of emergency at the state or national level.
Out-of-area services
Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield
licensees. Generally, these relationships are called Inter-Plan Arrangements and they
work based on rules and procedures issued by the Blue Cross Blue Shield Association.
Whenever you receive health care services outside of California, the claims for those
services may be processed through one of these Inter-Plan Arrangements described
below.
When you access health care services outside of the Plan Service Area, you will receive
the care from one of two kinds of providers. Most providers are participating providers
and contract with the local Blue Cross and/or Blue Shield licensee in that other
geographic area (Host Blue). Some providers are non-participating providers because
they do not contract with the Host Blue. Blue Shield’s payment practices in both
instances are described below and in the Introduction section of this Agreement.
This Blue Shield plan provides limited coverage for health care services received outside
of the Plan Service Area. Out-of-Area Covered Health Care Services are restricted to
Emergency Services, Urgent Services, and Out-of-Area Follow-up Care. Any other
services will not be covered when processed through an Inter-Plan Arrangement unless
prior authorized by Blue Shield. Please see the Medical Management Programs section
for additional information on prior authorization and the Emergency Benefits section for
information on emergency admission notification.
See the Care outside of California section for more information

about receiving care while outside of California. To find
participating providers while outside of California, visit
bcbs.com.
Inter-Plan Arrangements
Emergency Services
Members who experience an Emergency Medical Condition while traveling
outside of California should seek immediate care from the nearest Hospital. The
Benefits of this plan will be provided anywhere in the world for treatment of an
Emergency Medical Condition.
BlueCard® Program
Under the BlueCard® Program, when you receive Out-of-Area Covered Health
Care Services within the geographic area served by a Host Blue, Blue Shield will
remain responsible for the provisions of this Agreement. However, the Host Blue is
responsible for contracting with and generally handling all interactions with its
participating healthcare providers, including direct payment to the provider.
The BlueCard® Program enables you to obtain Out-of-Area Covered Health Care
Services, as defined above, from a health care provider participating with a Host
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Blue, where available. The participating health care provider will automatically
file a claim for the Out-of-Area Covered Health Care Services provided to you,
so there are no claim forms for you to fill out. You will be responsible for your Cost
Share, if any, as stated in the Summary of Benefits.
When you receive Out-of-Area Covered Health Care Services and the claim is
processed through the BlueCard® Program, your Member share of cost for these
services, if not a flat dollar Copayment, is calculated based on the lower of:
• The billed charges for your Out-of-Area Covered Health Care Services; or
• The negotiated price that the Host Blue makes available to Blue Shield.
Often, this negotiated price will be a simple discount that reflects an actual price
that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated
price that takes into account special arrangements with your healthcare
provider or provider group that may include types of settlements, incentive
payments, and/or other credits or charges. Occasionally, it may be an average
price, based on a discount that results in expected average savings for similar
types of healthcare providers after taking into account the same types of
transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account
adjustments to correct for over- or underestimation of modifications of past
pricing as noted above. However, such adjustments will not affect the price Blue
Shield uses for your claim because these adjustments will not be applied
retroactively to claims already paid.
Claims for covered Emergency Services are paid based on the Allowable
Amount as defined in this Evidence of Coverage.
Non-Participating Providers outside of California

Coverage for health care services provided outside of California and
within the BlueCard® Service Area by non-participating providers is limited
to Out-of-Area Covered Health Care Services. The amount you pay for
such services will normally be based on either the Host Blue’s non-
participating provider local payment, the Allowable Amount Blue Shield
pays a Non-Participating Provider in California if the Host Blue has no non-
participating provider allowance, or the pricing arrangements required by
applicable state or federal law. In these situations, you will be responsible
for any difference between the amount that the non-participating
provider bills and the payment Blue Shield will make for Out-of-Area
Covered Health Care Services as described in this paragraph.
If you do not see a participating provider through the BlueCard® Program,
you will have to pay the entire bill for your medical care and submit a
claim to the local Blue Cross and/or Blue Shield plan, or to Blue Shield of
California for reimbursement. Blue Shield will review your claim and notify
you of its coverage determination within 30 days after receipt of the
claim; you will be reimbursed as described in the preceding paragraph.
Remember, your share of cost is higher when you see a non-participating
provider.
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Your Cost Share for out-of-network Emergency Services will be the same
as the amount due to a Participating Provider for such Covered Services,
as listed in the Summary of Benefits.
Blue Shield Global® Core

If you are outside of the BlueCard® Service Area, you may be able to take
advantage of Blue Shield Global® Core when accessing Out-of-Area Covered
Health Care Services. Blue Shield Global® Core is unlike the BlueCard® Program
available within the BlueCard® Service Area in certain ways. For instance, the
network is not served by a Host Blue. As such, when you receive care from providers
outside the BlueCard® Service Area, you will typically have to pay the providers and
submit the claims yourself to obtain reimbursement for these services.
If you need assistance locating a doctor or hospital outside the BlueCard® Service
Area you should call the service center at (800) 810-BLUE (2583) or call collect at
(804) 673-1177, 24 hours a day, seven days a week. Provider information is also
available online at www.bcbs.com: select Find a Doctor and then “Blue Shield
Global Core.”
Prior authorization is not required for Emergency Services. In an emergency, go
directly to the nearest hospital. Please see the Medical Management Programs
section for additional information on emergency admission notification.
Submitting a Blue Shield Global® Core claim

When you pay directly for Out-of-Area Health Care Services outside the
BlueCard® Service Area, you must submit a claim to obtain reimbursement. You
should complete a Blue Shield Global® Core claim form and send the claim form
along with the provider’s itemized bill to the service center at the address
provided on the form to initiate claims processing. Following the instructions on
the claim form will help ensure timely processing of your claim. The claim form is
available from Blue Shield Customer Service, the service center or online at
www.bcbsglobalcore.com. If you need assistance with your claim submission,
you should call the service center at (800) 810-BLUE (2583) or call collect at (804)
673-1177, 24 hours a day, seven days a week.
Limitation for duplicate coverage

Medicare
If you receive Medicare, Blue Shield will provide your Benefits but Medicare will
typically be the primary payor and Blue Shield will be the secondary payor as
determined by Medicare regulations.
When Blue Shield is the secondary payor, your combined Benefits from Medicare
and Blue Shield will equal but not exceed what Blue Shield would pay if you were not
eligible for Medicare. Blue Shield’s payment will be based on an amount that may
be lower than the Medicare allowed amount but will not exceed the Medicare
allowed amount. You must pay any applicable Deductibles, Copayments, and
Coinsurance for your Blue Shield plan before Blue Shield will provide Benefits.
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Medi-Cal
Medi-Cal always pays for Benefits last when you have coverage from more than one
payor.
Qualified veterans
If you are a qualified veteran, Blue Shield will pay the reasonable value or the
Allowable Amount for Covered Services you receive at a Veterans Administration
facility for a condition that is not related to military service. If you are a qualified
veteran who is not on active duty, Blue Shield will pay the reasonable value or the
Allowable Amount for Benefits you receive at a Department of Defense facility. This
includes Benefits for conditions related to military service.
Coverage by another government agency

If you are entitled to receive Benefits from any federal or state governmental
agency, by any municipality, county, or other political subdivision, your combined
Benefits from that coverage and Blue Shield will equal but not be more than what
Blue Shield would pay if you were not eligible for Benefits under that coverage. Blue
Shield will provide Benefits based on the reasonable value or the Allowable Amount.
Exception for other coverage

A Participating Provider may seek reimbursement from other third-party payors for the
balance of their charges for services you receive under this plan.
If you recover from a third party the reasonable value of Covered Services received
from a Participating Provider, the Participating Provider is not required to accept the
fees paid by Blue Shield as payment in full. You may be liable to the Participating
Provider for the difference, if any, between the fees paid by Blue Shield and the
reasonable value recovered for those services.
Reductions – third-party liability

If you are injured or become ill due to the act or omission of another person (a “third
party”), Blue Shield shall, with respect to services required as a result of that injury,
provide the Benefits of the plan and have an equitable right to restitution,
reimbursement, or other available remedy to recover the amounts Blue Shield paid for
services provided to you on a fee-for-service basis from any recovery (defined below)
obtained by or on your behalf, from or on behalf of the third party responsible for the
injury or illness or from uninsured/underinsured motorist coverage.
Blue Shield’s right to restitution, reimbursement, or other available remedy is against any
recovery you receive as a result of the injury or illness. This includes any amount
awarded to you or received by way of court judgment, arbitration award, settlement,
or any other arrangement, from any third party or third-party insurer, or from uninsured
or underinsured motorist coverage, related to the illness or injury (the “Recovery”),
whether or not you have been “made whole” by the Recovery. The amount Blue Shield
seeks as restitution, reimbursement, or other available remedy will be calculated in
accordance with California Civil Code section 3040.
You are required to:
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• Notify Blue Shield in writing of any actual or potential claim or legal action which
you expect to bring or have brought against the third party arising from the
alleged acts or omissions causing the injury or illness, not later than 30 days after
submitting or filing a claim or legal action against the third party;
• Cooperate with Blue Shield to execute any forms or documents needed to
enable Blue Shield to enforce its right to restitution, reimbursement, or other
available remedies;
• Agree in writing to reimburse Blue Shield for Benefits paid by Blue Shield from any
Recovery when the Recovery is obtained from or on behalf of the third party or
the insurer of the third party, or from uninsured or underinsured motorist
coverage;
• Provide Blue Shield with a lien in the amount of Benefits actually paid. The lien
may be filed with the third party, the third party's agent or attorney, or the court,
unless otherwise prohibited by law; and
• Periodically respond to information requests regarding the claim against the third
party, and notify Blue Shield, in writing, within ten days after any Recovery has
been obtained.
Your failure to comply with the above shall not in any way act as a waiver, release, or
relinquishment of the rights of Blue Shield.
Further, if you received services from a Participating Hospital for such injuries or illness,
the Hospital has the right to collect from you the difference between the amount paid
by Blue Shield and the Hospital’s reasonable and necessary charges for such services
when payment or reimbursement is received by you for medical expenses. The
Hospital’s right to collect shall be in accordance with California Civil Code Section
3045.1.
Reductions – Surrogacy Arrangement

If you enter into a Surrogacy Arrangement and you or any other payee are entitled
to receive payments or other compensation under the Surrogacy Arrangement, you
must reimburse Blue Shield for Covered Services you receive related to conception,
pregnancy, delivery, or postpartum care in connection with the Surrogacy. This
Surrogacy Arrangement section does not affect your obligation to pay your Cost
Share for these Covered Services. After you surrender a baby to the legal parents,
the legal parents are financially responsible for any services that the baby receives.
You are not obligated to reimburse Blue Shield for any services that the baby
receives.
By receiving Covered Services in connection with a Surrogacy Arrangement, you
automatically assign to Blue Shield your right to receive payments that are payable
to you or any other payee under the Surrogacy Arrangement, regardless of whether
those payments are characterized as being for medical expenses. To secure our
rights, we will also have a lien on those payments and on any escrow account, trust,
or any other account that holds those payments. Those payments and amounts in
any account that holds those payments will first be applied to satisfy our lien. The
assignment and our lien will not exceed the total amount of your obligation to Blue
Shield under the preceding paragraph.
Within 30 days after entering into a Surrogacy Arrangement, you must send written
notice of the arrangement, including all of the following information:
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• Names, addresses, and telephone numbers of the other parties to the Surrogacy
Arrangement;
• Names, addresses, and telephone numbers of any escrow agent or trustee;
• Names, addresses, and telephone numbers of the intended parents and any
other parties who are financially responsible for Covered Services the baby (or
babies) receive, including names, addresses, and telephone numbers for any
health insurance that will cover services that the baby (or babies) receive;
• A signed copy of any contracts and other documents explaining the Surrogacy
Arrangement; and
• Any other information we request in order to satisfy our rights.
Please send this information to:
Surrogacy Mailbox
P.O. Box 3008
Lodi, Ca 95241-1912
You must complete and send Blue Shield all consents, releases, authorizations, lien
forms, and other documents that are reasonably necessary for us to determine the
existence of any rights we may have under this Surrogacy Arrangement section and
to satisfy those rights. You may not agree to waive, release, or reduce our rights
under this Surrogacy Arrangement section without our prior, written consent.
If your estate, parent, guardian, or conservator asserts a claim against a third party
based on the Surrogacy Arrangement, your estate, parent, guardian, or conservator
and any settlement or judgment recovered by the estate, parent, guardian, or
conservator will be subject to our liens and other rights to the same extent as if you
had asserted the claim against the third party. Blue Shield may assign our rights to
enforce our liens and other rights.
General provisions
Independent contractors
Providers are neither agents nor employees of Blue Shield but are independent
contractors. In no instance shall Blue Shield be liable for the negligence, wrongful
acts, or omissions of any person providing services, including any Physician, Hospital,
or other Health Care Provider or their employees.
Assignment
Coverage under this Agreement may not be assigned. To be entitled to the Benefits
of this Agreement, you must be a Subscriber or Dependent who has been enrolled
by Blue Shield and who has maintained eligibility and enrollment under the terms of
this Agreement. Possession of a Blue Shield ID card without enrollment confers no
rights to the Benefits of this Agreement.
The Benefits of this Agreement, including payment of claims, may not be assigned
without the written consent of Blue Shield. Participating Providers are paid directly by
Blue Shield. When you receive Covered Services from a Non-Participating Provider,
Blue Shield, at its sole discretion, may make payment to the Subscriber or directly to
the Non-Participating Provider. If Blue Shield pays the Non-Participating Provider
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directly, such payment does not create a third-party beneficiary or other legal
relationship between Blue Shield and the Non-Participating Provider. The Subscriber
must make sure the Non-Participating Provider receives the full billed amount for non-
emergency services, whether or not Blue Shield makes payment to the Non-
Plan interpretation
Blue Shield shall have the power and authority to construe and interpret the
provisions of this Agreement, to determine the Benefits of this Agreement and to
implement eligibility determinations made by Covered California. Blue Shield shall
exercise this authority for the benefit of all Members entitled to receive Benefits under
this Agreement.
Public policy participation procedure

Blue Shield allows Members to participate in establishing the public policy of Blue
Shield. Such participation is not to be used as a substitute for the grievance process.
Recommendations, suggestions or comments should be submitted in writing to:
Sr. Manager, Regulatory Filings
601 12th Street
Oakland, CA 94607
Phone: (510) 607-2065
Please include your name, address, phone number, and Subscriber number with
each communication. Please state the public policy issue clearly. Submit all relevant
information and reasons for the policy issue with your letter.
Public policy issues will be heard as agenda items for meetings of the Board of
Directors. Minutes of Board meetings will reflect decisions on public policy issues that
were considered. Members who have initiated a public policy issue will be furnished
with the appropriate extracts of the minutes.
At least one third of the Board of Directors is comprised of Subscribers who are not
employees, providers, subcontractors or group contract brokers and who do not
have financial interests in Blue Shield. The names of the members of the Board of
Directors may be obtained from the Sr. Manager, Regulatory Filings as listed above.
Access to information
Blue Shield may need information from medical providers, from other carriers, from
Covered California or other entities, or from the Member, in order to administer the
Benefits and eligibility provisions of this Agreement. By enrolling in this health plan,
each Member agrees that any provider or entity can disclose to Blue Shield that
information that is reasonably needed by Blue Shield. Members also agree to assist
Blue Shield in obtaining this information, if needed, (including signing any necessary
authorizations) and to cooperate by providing Blue Shield with information in the
Member’s possession. Failure to assist Blue Shield in obtaining necessary information
or refusal to provide information reasonably needed may result in the delay or denial
of Benefits until the necessary information is received. Any information received for
this purpose by Blue Shield will be maintained as confidential and will not be
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disclosed without the Member’s consent, except as otherwise permitted or required

by law.
Legal process
Legal process or service upon Blue Shield must be served upon Blue Shield’s
Registered Agent for Service of Process or upon Blue Shield at Blue Shield’s corporate
offices at 601 12th Street, Oakland, California 94607.
Notice of Participating Provider’s inability to perform, breach, or termination

If a Participating Provider’s inability to perform, breach of the Agreement to furnish
services, or contract termination materially and adversely affects the Member, Blue
Shield will, within a reasonable time, advise the Member in writing of such inability to
perform, breach, or termination.
Entire Agreement: changes

This Agreement, including the Evidence of Coverage and Health Service Agreement,
the Summary of Benefits, enrollment applications and forms, and appendices,
constitutes the entire agreement between the parties. Any statement made by a
Blue Shield representative shall, in the absence of fraud, be deemed a
representation and not a warranty.
No change to this Agreement shall be valid unless approved by a corporate officer
of Blue Shield and documented in a written endorsement issued by Blue Shield. No
representative has the authority to change this Agreement or to waive any of its
provisions. The terms of this Agreement, including but not limited to Benefits,
exclusions, Cost Share, and Premiums, are subject to change as permitted by law.
Blue Shield will give the Subscriber written notice of Premium rates or coverage
changes, unless otherwise specified in the Changes to Premiums section. We will
send this notice at least 60 days prior to plan renewal.
Right of recovery
Whenever payment on a claim is made in error, Blue Shield has the right to recover
such payment from the Subscriber or, if applicable, the provider or another health
benefit plan, in accordance with applicable laws and regulations. With notice, Blue
Shield reserves the right to deduct or offset any amounts paid in error from any
pending or future claim to the extent permitted by law. Circumstances that might
result in payment of a claim in error include, but are not limited to, payment of
benefits in excess of the benefits provided by the health plan, payment of amounts
that are the responsibility of the Subscriber (Cost Share or similar charges), payment
of amounts that are the responsibility of another payor, payments made after
termination of the Subscriber’s coverage, or payments made on fraudulent claims.
Endorsements and appendices

Attached to, or incorporated by reference into, this Agreement are appendices
pertaining to Premiums. Endorsements may be issued from time to time subject to the
notice provisions in the section entitled Entire Agreement: changes. The issuance of
an endorsement shall not affect this Agreement, except as expressly provided in the
endorsement.
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Notices
Any notice required by this Agreement may be delivered by United States mail,
postage prepaid. Notices to the Subscriber may be mailed to the address appearing
on the records of Blue Shield.
Notice to Blue Shield may be mailed to:
601 12th Street
Oakland, CA 94607
Statutory requirements
This Agreement is subject to applicable state law and related regulations, including
the Knox-Keene Health Care Service Plan Act, Chapter 2.2 of Division 2 of the
California Health and Safety Code and Title 28 of the California Code of Regulations,
or in the alternative the Insurance Code, and Title 10 of the California Code of
Regulations. Any provision required to be in this Agreement based on such state law
or regulation shall be binding upon the Subscriber and Blue Shield whether or not
such provision is actually included in this Agreement.
In addition, this Agreement is subject to applicable federal law, including the Patient
Protection and Affordable Care Act of 2010 (PPACA), the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the
Health Insurance Portability and Accountability Act of 1996 (HIPAA), and related
regulations. Any provision required to be in this Agreement based on such federal
law or regulation shall be binding upon the Subscriber and Blue Shield whether or not
such provision is actually included in this Agreement.
Blue Cross Blue Shield Association Disclosure

The Subscriber hereby expressly acknowledges his or her understanding that this
Agreement constitutes a contract solely between the Subscriber and Blue Shield of
California, which is an independent corporation operating under a license from the
Blue Cross Blue Shield Association (Association), an association of independent Blue
Cross and Blue Shield licensees, permitting Blue Shield to use the Blue Shield Service
Mark in the State of California and that Blue Shield is not contracting as the agent of
the Association.
The Subscriber further acknowledges and agrees that he or she has not entered into
this Agreement based upon representations by any person other than Blue Shield or
Blue Shield’s authorized representative and that neither the Association nor any
person, entity or organization affiliated with the Association, shall be held
accountable or liable to the Subscriber for any Blue Shield obligations created under
this Agreement. This paragraph shall not create any additional obligations to the
Subscriber whatsoever on the part of Blue Shield, other than those obligations
created under other provisions of this Agreement.
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Definitions
Activities related to independence in normal everyday living.

Activities of Daily
Recreational, leisure, or sports activities are not considered
Living
Activities of Daily Living.
An event, series of events, or set of circumstances that is

Adverse Childhood experienced by an individual as physically or emotionally
Experiences harmful or threatening and that has lasting adverse effects on
the individual’s functioning and physical, social, emotional, or
spiritual well-being.
Agreement Evidence of Coverage and Health Service Agreement,

(Evidence of Summary of Benefits, all endorsements, appendices, and all
Coverage and applications and forms for coverage.
Health Service
Agreement)
The maximum amount Blue Shield will pay for Covered

Services, or the provider’s billed charge for those Covered
Services, whichever is less. Unless specified for a particular
service elsewhere in this Agreement, the Allowable Amount is:
• For a Participating Provider: the amount that the
provider and Blue Shield have agreed by contract will
be accepted as payment in full for the Covered
Service rendered.
• For a Non-Participating Provider who provides
Emergency Services:
o Physicians and Hospitals: the amount is the
Reasonable and Customary amount; or
o All other providers: (1) the amount is the provider’s
billed charge for Covered Services, unless the
Allowable Amount provider and the local Blue Cross and/or Blue Shield
plan have agreed upon some other amount, or (2)
if applicable, the amount determined under state
and federal laws.
• For a Non-Participating Provider in California who
provides services other than Emergency Services:
o The amount Blue Shield would have allowed for a
Participating Provider performing the same service
in the same geographical area but not exceeding
any stated Benefit maximum;
o Non-Participating dialysis center: for services prior
authorized by Blue Shield, the amount is the
Reasonable and Customary amount.
• For a provider outside of California but inside the
BlueCard® Service Area, the lower of:
o The provider’s billed charge, or
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Definitions 111
o The local Blue Plan’s Participating Provider payment

or the pricing arrangement required by applicable
state law.
• For a provider outside California and outside the
BlueCard® Service Area, the amount allowed by Blue
Shield Global Core.
• For a Non-Participating Provider outside of California
(within the BlueCard® Service Area) that does not
contract with a local Blue Cross and/or Blue Shield
plan, who provides services other than Emergency
Services: the amount that the local Blue Cross and/or
Blue Shield plan would have allowed for a Non-
Participating Provider performing the same services. Or,
if the local Blue Cross and/or Blue Shield plan has no
Non-Participating Provider allowance, the Allowable
Amount is the amount for a Non-Participating Provider
in California. Or, if applicable, the amount determined
under federal law.
• For Blue Shield’s contracted Benefit Administrators
(MHSA, DPA, VPA), the Allowable Amount is based on
the administrator’s contracted rate for its participating
providers.
Where required under federal law, the Allowable Amount
used to determine your Cost Share may be based on the
plan’s “qualifying payment amount,” which may differ from
the amount Blue Shield pays the Non-Participating Provider or
facility for Covered Services.
An outpatient surgery facility that meets both of the following
requirements:
Ambulatory Surgery • Is a licensed facility accredited by an ambulatory
Center surgery center accrediting body; and
• Provides services as a free-standing ambulatory surgery
center, which is not otherwise affiliated with a Hospital.
Anticancer Drugs used to kill or slow the growth of cancerous cells.

Medications
ASH Participating A Physician or Health Care Provider under contract with ASH
Provider Plans to provide Covered Services to Members.
The continuum of services to address crisis intervention, crisis

stabilization, and crisis residential treatment needs of those
with a mental health or substance use disorder crisis that are
Behavioral Health
wellness, resiliency, and recovery oriented. These include, but
Crisis Services
are not limited to, crisis intervention, including counseling
provided by 988 centers, Mobile Crisis Teams, and crisis
receiving and stabilization services.
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Professional services and treatment programs that develop or

restore, to the maximum extent practicable, the functioning
Behavioral Health
of an individual with pervasive developmental disorder or
Treatment (BHT)
autism. BHT includes applied behavior analysis and evidence-
based intervention programs.
Benefits (Covered Medically Necessary services and supplies you are entitled to
Services) receive pursuant to this Agreement.
Administrator for specialized Benefits such as pediatric dental,

Benefit Administrator pediatric vision, or Mental Health and Substance Use Disorder
Benefits.
Drugs that are FDA-approved that are highly similar to an

FDA-approved biologic (reference product) with no clinically
Biosimilar Drugs
meaningful differences in terms of safety, purity, strength and
effectiveness.
California Physicians' Service, d/b/a Blue Shield of California, is

Blue Shield of a California not-for-profit corporation, licensed as a health
California care service plan. It is referred to throughout this Agreement
as Blue Shield.
BlueCard® Service The United States, Commonwealth of Puerto Rico, and U.S.
Area Virgin Islands.
Drugs that are FDA-approved after a new drug application

Brand Drugs and/or registered under a brand or trade name by its
manufacturer.
The 12-month consecutive period beginning on January 1

Calendar Year
and ending on December 31 of the same year.
The percentage amount that a Member is required to pay for

Coinsurance
Covered Services after meeting any applicable Deductible.
Nursing care provided on a continuous hourly basis, rather

than intermittent home visits for Members enrolled in a
Continuous Nursing Hospice Program. Continuous home care can be provided by
Services a registered or licensed vocational nurse, but is only available
for brief periods of crisis and only as necessary to maintain the
terminally ill patient at home.
The specific dollar amount that a Member is required to pay

Copayment for Covered Services after meeting any applicable
Deductible.
Cost Share Any applicable Deductibles, Copayment, and Coinsurance.
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Covered Services Medically Necessary services and supplies you are entitled to
(Benefits) receive pursuant to this Agreement.
The Calendar Year amount you must pay for specific

Deductible Covered Services before Blue Shield pays for Covered
Services pursuant to this Agreement.
The Dental Allowable Amount is:

• The amount the DPA has determined is an appropriate
payment for the service rendered in the provider's
geographic area. This amount is based upon such
factors as evaluation of the value of the service
relative to the value of other services, market
Dental Allowable considerations, and provider charge patterns;
Amount • Such other amount as the Participating Dentist and the
DPA have agreed will be accepted as payment for the
service rendered; or
• If an amount is not determined as described in either
item above, the amount the DPA determines is
appropriate due to the particular circumstances and
the services rendered.
Necessary treatment on or to the teeth or gums, including any

appliance or device applied to the teeth or gums, and
Dental Care Services
necessary dental supplies furnished incidental to Dental Care
Services.
A Dentist or a dental practice (with one or more Dentists) that

has contracted with the DPA to provide dental care Benefits
Dental Center to Members and to diagnose, provide, refer, supervise, and
coordinate the provision of all Benefits to Members in
accordance with this Agreement.
Blue Shield has contracted with a Dental Plan Administrator

(DPA). A DPA is a specialized care service plan licensed by
the California Department of Managed Health Care. Blue
Dental Plan
Shield contracts with the DPA to administer delivery of dental
Administrator (DPA)
services through a network of Participating Dentists. A DPA
also serves as a claims administrator for the processing of
claims received from non-Participating Dentists.
A Dentist or provider appropriately licensed to provide Dental

Care Services who contracts with a Dental Center to provide
Dental Provider
Benefits to you in accordance with the dental services
contract.
A duly licensed Doctor of Dental Surgery (DDS) or Doctor of

Dentist
Dental Medicine (DMD).
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Definitions 114
An individual who meets one of the following eligibility

requirements:
• A qualifying parent or stepparent.
• A spouse who is legally married to the Subscriber and
who is not legally separated from the Subscriber.
• A Domestic Partner to the Subscriber who meets the
definition of Domestic Partner as defined in this
Agreement.
• A child who is the child of, adopted by, or in legal
guardianship of the Subscriber, spouse, or Domestic
Dependent Partner, and who is not covered as a Subscriber. A
child includes any stepchild, child placed for adoption,
or any other child for whom the Subscriber, spouse, or
Domestic Partner has been appointed as a non-
temporary legal guardian by a court of appropriate
legal jurisdiction. A child is an individual less than 26
years of age. A child does not include any children of
a Dependent child (grandchildren of the Subscriber,
spouse, or Domestic Partner), unless the Subscriber,
spouse, or Domestic Partner has adopted or is the legal
guardian of the grandchild.
An individual who is personally related to the Subscriber by a

domestic partnership that meets the following requirements:
• Both partners are 18 years of age or older, except as
provided in Section 297.1 of the California Family
Code;
• The partners have chosen to share one another’s lives
in an intimate and committed relationship of mutual
caring;
• The partners are:
o not currently married to someone else or a
Domestic Partner member of another domestic partnership; and
o not so closely related by blood that legal
marriage or registered domestic partnership
would otherwise be prohibited;
• Both partners are capable of consenting to the
domestic partnership; and
• Both partners must file a Declaration of Domestic
Partnership with the California Secretary of State,
pursuant to the California Family Code.
The domestic partnership is deemed created on the date
when both partners meet the above requirements.
Drugs include the following:

Drugs • FDA-approved medications that require a prescription
either by California or Federal law;
• Insulin;
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• Pen delivery systems for the administration of insulin, as

Medically Necessary;
• Self-applied continuous blood glucose monitors, and
all related necessary supplies;
• Diabetic testing supplies, including the following:
o Lancets;
o Lancet puncture devices;
o Blood and urine testing strips; and
o Test tablets;
• Over-the-counter drugs with a United States Preventive
Services Task Force (USPSTF) rating of A or B;
• Contraceptive drugs, devices, and products, including
the following:
o Diaphragms;
o Cervical caps;
o Contraceptive rings;
o Contraceptive patches;
o Oral contraceptives;
o Emergency contraceptives; and
o Over-the-counter contraceptive products;
• Disposable devices that are Medically Necessary for
the administration of a covered outpatient prescription
Drug such as syringes and inhaler spacers.
A provider who has an agreement in effect with the Dental

DPA Participating
Plan Administrator (DPA) for the provision of pediatric dental
Provider
Benefits under this plan.
An unexpected dental condition manifesting itself by acute

symptoms of sufficient severity, including severe pain, such
that you reasonably believe the absence of immediate
Emergency Dental medical attention could result in any of the following:
Condition
• Placing your health in serious jeopardy;
• Serious impairment to bodily functions; or
• Serious dysfunction of any bodily organ or part.
A medical condition, including a psychiatric emergency,

manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that you reasonably believe the
absence of immediate medical attention could result in any
of the following:
Emergency Medical • Placing your health in serious jeopardy (including the
Condition health of a pregnant woman or her unborn child);
• Serious impairment to bodily functions;
• Serious dysfunction of any bodily organ or part;
• Danger to yourself or to others; or
• Inability to provide for, or utilize, food, shelter, or
clothing, due to a mental disorder.
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The following services provided for an Emergency Medical

Condition:
• Medical screening, examination, and evaluation by a
Physician and surgeon, or other appropriately licensed
persons under the supervision of a Physician and
surgeon, to determine if an Emergency Medical
Condition or active labor exists and, if it does, the care,
treatment, and surgery necessary to relieve or
eliminate the Emergency Medical Condition, within the
capability of the facility;
• Additional screening, examination, and evaluation by
a Physician, or other personnel within the scope of their
licensure and clinical privileges, to determine if a
psychiatric Emergency Medical Condition exists, and
Emergency Services the care and treatment necessary to relieve or
eliminate the psychiatric Emergency Medical
Condition, within the capability of the facility; and
• Care and treatment necessary to relieve or eliminate a
psychiatric Emergency Medical Condition may include
admission or transfer to a psychiatric unit within a
general acute care Hospital or to an acute psychiatric
Hospital; and
• Solely to the extent required under the federal law,
Emergency Services also include any additional items
or services that are covered under the plan and
furnished by a Non-Participating Provider or
emergency facility, regardless of the department
where furnished, after stabilization and as part of
outpatient observation or inpatient or outpatient stay.
Any treatment, therapy, procedure, drug or drug usage,

facility or facility usage, equipment or equipment usage,
device or device usage, or supplies shall be considered
experimental or investigational if, as determined by Blue
Shield, at least one of the following elements is met:
• Requires approval by the Federal government or any
agency thereof, or by any State government agency,
prior to use and where such approval has not been
Experimental or
granted at the time the services or supplies were
Investigational
rendered; or
• Is not recognized in accordance with generally
accepted professional medical standards as being
safe and effective for use in the treatment of the illness,
injury, or condition at issue, but nevertheless is
authorized by law or by a government agency for use;
or
• Is not approved or recognized in accordance with
accepted professional medical standards, but
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nevertheless is authorized by law or by a government

agency for use in testing, trials, or other studies on
human patients; or
• Is not recognized or not recommended by nationally
recognized treatment guidelines by a specialty society
or medical review organization, if applicable, or where
the consensus amongst experts in recognized
published medical literature is that further studies or
experience are necessary to determine effectiveness
and net health benefit in treatment of the illness, injury,
or condition at issue, but nevertheless are authorized
by law or by a government agency for use.
Family The Subscriber and all enrolled Dependents.
A Former Participating Provider is a provider of services to the

Member under any of the following conditions:
• A provider who is no longer available to you as a
Participating Provider or an MHSA Participating
Provider, but at the time of the provider's contract
termination with Blue Shield or the MHSA, you were
receiving Covered Services from that provider for one
of the conditions listed in the Continuity of care with a
Former Participating Former Participating Provider table in the Continuity of
Provider care section.
• A Non-Participating Provider to a newly-covered
Member whose health plan was withdrawn from the
market, and at the time your coverage with Blue Shield
became effective, you were receiving Covered
Services from that provider for one of the conditions
listed in the Continuity of care with a Former
Participating Provider table in the Continuity of care
section.
A list of preferred Generic and Brand Drugs maintained by

Blue Shield’s Pharmacy & Therapeutics Committee. It is
designed to assist Physicians in prescribing Drugs that are
Formulary Medically Necessary and cost-effective. The Formulary is
updated periodically. Benefits are available for Formulary
Drugs. Non-Formulary Drugs are covered when Blue Shield or
an external reviewer approves an exception request.
Standards of care and clinical practice that are generally

Generally Accepted recognized by Health Care Providers practicing in relevant
Standards of Mental clinical specialties such as psychiatry, psychology, clinical
Health and sociology, addiction medicine and counseling, and
Substance Use behavioral health treatment. Valid, evidence-based sources
Disorder Care establishing generally accepted standards of Mental Health
and Substance Use Disorder care include:
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• Peer-reviewed scientific studies and medical literature;

• Clinical practice guidelines and recommendations of
nonprofit health care provider professional
associations;
• Specialty societies and federal government agencies;
and
• Drug labeling approved by the United States Food and
Drug Administration.
Drugs that are approved by the U.S. Food and Drug

Administration (FDA) or other authorized government agency
Generic Drugs
as a therapeutic equivalent to the Brand Drug. Generic Drugs
contain the same active ingredient(s) as Brand Drugs.
An appropriately licensed or certified professional who

provides health care services within the scope of that license,
including, but not limited to:
• Acupuncturist;
• Associate clinical social worker;
• Associate marriage and family therapist or marriage
and family therapist trainee;
• Associate professional clinical counselor or professional
clinical counselor trainee;
• Audiologist;
• Board certified behavior analyst (BCBA);
• Certified nurse midwife;
• Chiropractor;
• Clinical nurse specialist;
• Dentist;
• Hearing aid supplier;
Health Care Provider • Licensed clinical social worker;
• Licensed midwife;
• Licensed professional clinical counselor (LPCC);
• Licensed vocational nurse;
• Marriage and family therapist;
• Naturopath;
• Nurse anesthetist (CRNA);
• Nurse practitioner;
• Occupational therapist;
• Optician;
• Optometrist;
• Pharmacist;
• Physical therapist;
• Physician;
• Physician assistant;
• Podiatrist;
• Psychiatric/mental health registered nurse;
• Psychologist;
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Definitions 119
• Psychology trainee or person supervised as required by

law;
• Qualified autism service provider or qualified autism
service professional certified by a national entity;
• Registered dietician;
• Registered nurse;
• Registered psychological assistant;
• Registered respiratory therapist;
• Speech and language pathologist.
A provider that furnishes blood factor replacement products

and services for in-home treatment of blood disorders such as
hemophilia.
Hemophilia Home
Infusion Provider A Participating home infusion agency may not be a
Participating Hemophilia Infusion Provider if it does not have
an agreement with Blue Shield to furnish blood factor
replacement products and services.
An individual who has successfully completed a state-

approved training program, is employed by a home health
Home Health Aide
agency or Hospice program, and provides personal care
services in the home.
An entity that meets one of the following criteria:

• A licensed and accredited facility primarily engaged in
providing medical, diagnostic, surgical, or psychiatric
services for the care and treatment of sick and injured
persons on an inpatient basis, under the supervision of
Hospital an organized medical staff, and that provides 24-hour
a day nursing service by registered nurses;
• A psychiatric health care facility as defined in Section
1250.2 of the California Health and Safety Code.
A facility that is principally a rest home, nursing home, or
home for the aged, is not included in this definition.
The local Blue Cross and/or Blue Shield licensee in a

Host Blue geographic area outside of California, within the BlueCard®
Service Area.
May be either of the following:

• A demonstrated condition recognized by a licensed
Infertility Physician or surgeon as a cause for Infertility; or
• The inability to conceive a pregnancy or to carry a
pregnancy to a live birth after a year of regular sexual
relations without contraception.
Intensive Outpatient An outpatient treatment program for mental health or

Program substance use disorders that provides structure, monitoring,
9705.
Definitions 120
and medical/psychological intervention at least three hours

per day, three times per week.
Blue Shield’s relationships with other Blue Cross and/or Blue

Inter-Plan
Shield licensees, governed by the Blue Cross Blue Shield
Arrangements
Association.
A bilateral impairment to vision that is so significant that it

cannot be corrected with ordinary eyeglasses, contact
lenses, or intraocular lens implants. Although reduced central
or reading vision is common, low vision may also result from
Low Vision
decreased peripheral vision, a reduction or loss of color vision,
or the eye’s inability to properly adjust to light, contrast, or
glare. It can be measured in terms of visual acuity of 20/70 to
20/200.
Benefits are provided only for services that are Medically

Necessary.
Services that are Medically Necessary include only those
which have been established as safe and effective, are
furnished under generally accepted professional standards to
treat illness, injury, or medical condition, and which, as
determined by Blue Shield, are:
• Consistent with Blue Shield medical policy;
• Consistent with the symptoms or diagnosis;
• Not furnished primarily for the convenience of the
patient, the attending Physician or other provider;
• Furnished at the most appropriate level that can be
provided safely and effectively to the patient; and
• Not more costly than an alternative service or
Medical Necessity sequence of services at least as likely to produce
(Medically equivalent therapeutic or diagnostic results as to the
Necessary) diagnosis or treatment of the Member’s illness, injury, or
disease.
Hospital inpatient services that are Medically Necessary
include only those services that satisfy the above
requirements, require the acute bed-patient (overnight)
setting, and could not have been provided in a Physician’s
office, the Outpatient Department of a Hospital, or in another
lesser facility without adversely affecting the patient’s
condition or the quality of medical care rendered.
Inpatient admission is not Medically Necessary for certain
services, including, but not limited to, the following:
• Diagnostic studies that can be provided on an
outpatient basis;
• Medical observation or evaluation;
• Personal comfort;
9705.
Definitions 121
• Pain management that can be provided on an

outpatient basis; and
• Inpatient rehabilitation that can be provided on an
outpatient basis.
Blue Shield reserves the right to review all services to
determine whether they are Medically Necessary, and may
use the services of Physician consultants, peer review
committees of professional societies or Hospitals, and other
consultants.
This definition does not apply to Mental Health and Substance
Use Disorders. Medically Necessary Treatment of a Mental
Health or Substance Use Disorder is defined separately.
A Covered Service or product addressing the specific needs

of a Member, for the purpose of preventing, diagnosing, or
treating an illness, injury, condition, or its symptoms, including
minimizing the progression of an illness, injury, condition, or its
symptoms, in a manner that is all of the following:
Medically Necessary
Treatment of a • In accordance with the Generally Accepted
Mental Health or Standards of Mental Health and Substance Use
Substance Use Disorder Care;
Disorder • Clinically appropriate in terms of type, frequency,
extent, site, and duration; and
• Not primarily for the economic benefit of the disability
insurer and Members or for the convenience of the
patient, treating Physician, or other Health Care
Provider.
An individual who is enrolled and maintains coverage in the

plan pursuant to this Agreement as either a Subscriber or a
Member
Dependent. Use of “you” in this document refers to the
Member.
A mental health condition or substance use disorder that falls

under any of the diagnostic categories listed in the mental
Mental Health and
and behavioral disorders chapter of the most recent edition
Substance Use
of the International Statistical Classification of Diseases or
Disorder(s)
listed in the most recent version of the Diagnostic and
Statistical Manual of Mental Disorders (DSM).
The MHSA is a specialized health care service plan licensed

Mental Health by the California Department of Managed Health Care. Blue
Service Administrator Shield contracts with the MHSA to administer Blue Shield’s
(MHSA) Mental Health and Substance Use Disorder services through a
separate network of MHSA Participating Providers.
9705.
Definitions 122
A provider who does not have an agreement in effect with

MHSA Non-
the MHSA for the provision of mental health or substance use
Participating Provider
disorder services.
A provider who has an agreement in effect with the MHSA for

MHSA Participating
the provision of mental health or substance use disorder
Provider
services.
A multidisciplinary team of trained behavioral health

professionals who provide Behavioral Health Crisis Services in
Mobile Crisis Team
the least restrictive setting 24 hours a day, 7 days a week, 365
days per year.
Network Specialty Select Participating Pharmacies contracted by Blue Shield to

Pharmacy provide covered Specialty Drugs.
Any provider who does not participate in this plan’s network

and does not contract with Blue Shield to accept Blue Shield’s
Non-Participating
payment, plus any applicable Member Cost Share, or
(Non-Participating
amounts in excess of specified Benefit maximums, as
Provider)
payment in full for Covered Services. Also referred to as an
out-of-network provider.
A pharmacy that does not participate in the Blue Shield

Non-Participating
Pharmacy Network. These pharmacies are not contracted to
Pharmacy
provide services to Blue Shield Members.
Outpatient Facility and professional services for the diagnosis

and treatment of Mental Health and Substance Use Disorders,
including but not limited to the following:
• Partial Hospitalization;
Other Outpatient • Intensive Outpatient Program;
Mental Health and • Electroconvulsive therapy;
Substance Use • Office-based opioid treatment;
Disorder Services • Transcranial magnetic stimulation;
• Behavioral Health Treatment; and
• Psychological Testing.
These services may also be provided in the office, home, or
other non-institutional setting.
Medically Necessary Emergency Services, Urgent Services or

Out-of-Area Covered
Out-of-Area Follow-up Care provided outside the Plan Service
Health Care Services
Area.
Non-emergent Medically Necessary services to evaluate your

Out-of-Area Follow-
progress after Emergency or Urgent Services are provided
up Care
outside the Plan Service Area.
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Definitions 123
The highest Deductible, Copayment, and Coinsurance

amount an individual or Family is required to pay for
designated Covered Services each year as indicated in the
Out-of-Pocket
Summary of Benefits section. Charges for services that are not
Maximum
covered, charges in excess of the Allowable Amount or
contracted rate do not accrue to the Calendar Year Out-of-
Pocket Maximum.
Any department or facility integrated with the Hospital that

Outpatient
provides outpatient services under the Hospital’s license,
Department of a
which may or may not be physically separate from the
Hospital
Hospital.
A licensed facility that provides medical and/or surgical

Outpatient Facility services on an outpatient basis but is not a Physician’s office
or a Hospital.
An outpatient treatment program that may be free-standing

Partial Hospitalization or Hospital-based and provides services at least five hours per
Program (Day day, four days per week. You may be admitted directly to this
Treatment) level of care or transferred from inpatient care following
stabilization.
A Doctor of Dental Surgery or Doctor of Dental Medicine who

Participating Dentist has contracted with the DPA to provide dental services to
Members.
Participating Hospice An entity that has either contracted with Blue Shield or has
or Participating received prior approval from Blue Shield to provide Hospice
Hospice Agency service Benefits.
A provider who participates in this plan’s network and

Participating
contracts with Blue Shield to accept Blue Shield’s payment,
(Participating
plus any applicable Member Cost Share, as payment in full for
Provider)
Covered Services. Also referred to as an in-network provider.
A pharmacy that has contracted with Blue Shield to provide

Participating
covered Drugs at certain rates. A Participating Pharmacy
Pharmacy
participates in the Blue Shield Pharmacy Network.
An individual licensed and authorized to engage in the

Physician
practice of medicine.
A geographical area designated by the plan within which a

Plan Service Area
plan shall provide health care services.
The monthly prepayment amount made to Blue Shield on

Premium (Dues) behalf of each Member by the Contractholder for coverage
under this Agreement.
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Definitions 124
Preventive medical services for early detection of disease,

Preventive Health
including related laboratory services, as specifically described
Services
in the Preventive Health Services section.
A general or family practitioner, internist,

Primary Care obstetrician/gynecologist, or pediatrician. Your PCP will be
Physician (PCP) assigned to you at enrollment and can be your first point of
contact when you need Covered Services.
Dental Care Services specifically related to necessary

Prosthodontics procedures for providing artificial replacements for missing
natural teeth.
Testing to diagnose a mental health condition when referred

Psychological Testing
by an MHSA Participating Provider.
Qualified Health Plan A health plan that has been certified for sale through
(QHP) Covered California.
An enrollee deemed eligible for coverage by Covered

Qualified Individual
California.
In California: the lower of the provider’s billed charge or the

amount established by Blue Shield pursuant to applicable
state and federal law to be the reasonable and customary
value for the services rendered by a Non-Participating
Reasonable and Provider.
Customary
Outside of California: the lower of the provider’s billed charge
or the Participating Provider Cost Share for Emergency
Services as shown in the Summary of Benefits or if applicable,
the amount determined under state and federal law.
Surgery to correct or repair abnormal structures of the body

caused by congenital defects, developmental abnormalities,
trauma, infection, tumors, or disease to do either of the
Reconstructive following:
Surgery • Improve function; or
• Create a normal appearance to the extent possible,
including dental and orthodontic services that are an
integral part of surgery for cleft palate procedures.
An individual who spends in the aggregate more than 180

days each year within the State of California and has not
Resident of California
established a permanent residence in another state or
country.
Prescription Drugs or other substances that have a high

Schedule II
potential for abuse which may lead to severe psychological
Controlled Substance
or physical dependence.
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Definitions 125
Services performed by a licensed nurse who is either a

Skilled Nursing
registered nurse or a licensed vocational nurse.
A health facility or a distinct part of a Hospital with a valid

license issued by the California Department of Public Health
Skilled Nursing
that provides continuous Skilled Nursing care to patients
Facility (SNF)
whose primary need is for availability of Skilled Nursing care
on a 24-hour basis.
Specialists include Physicians with a specialty as follows:

• Allergy;
• Anesthesiology;
• Dermatology;
• Cardiology and other internal medicine specialists;
• Neonatology;
• Neurology;
• Oncology;
Specialist • Ophthalmology;
• Orthopedics;
• Pathology;
• Psychiatry;
• Radiology;
• Any surgical specialty;
• Otolaryngology;
• Urology; and
• Other designated as appropriate.
Drugs requiring coordination of care, close monitoring, or

extensive patient training for self-administration that cannot
be met by a retail pharmacy and are available exclusively
through a Network Specialty Pharmacy. Specialty Drugs may
Specialty Drugs
also require special handling or manufacturing processes
(such as biotechnology), restriction to certain Physicians or
pharmacies, or reporting of certain clinical events to the FDA.
Specialty Drugs are generally high-cost.
Skilled Nursing or skilled rehabilitation provided in a hospital or

Skilled Nursing Facility to patients who require skilled care such
as nursing services, physical, occupational or speech therapy,
Subacute Care a coordinated program of multiple therapies or who have
medical needs that require daily registered nurse monitoring.
A facility that is primarily a rest-home, convalescent facility, or
home for the aged is not included.
An individual who is a resident of California and has made

application individually or also on behalf of eligible
Subscriber Dependents, has been enrolled by Blue Shield, and has
maintained Blue Shield membership in accord with this
Agreement.
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Definitions 126
An arrangement in which a woman (the surrogate) agrees to

become pregnant and to surrender the baby (or babies) to
Surrogacy
another person (or persons) who intend to raise the child (or
Arrangement
children), whether or not the woman receives payment for
being a surrogate.
A corporation directly contracted with Blue Shield that

Third-Party
provides health care services exclusively through a telehealth
Corporate
technology platform and has no physical location at which a
Telehealth Provider
Member can receive services.
A change in your life that can make you eligible for a special
Triggering Event
enrollment period to enroll in health coverage.
Those Covered Services rendered outside of the Plan Service

Area (other than Emergency Services) which are Medically
Necessary to prevent serious deterioration of your health
Urgent Services resulting from unforeseen illness, injury or complications of an
existing medical condition, for which treatment cannot
reasonably be delayed until you return to the Plan Service
Area.
Blue Shield contracts with the Vision Plan Administrator (VPA)

Vision Plan to administer delivery of eyewear and eye exams covered
Administrator (VPA) under this Benefit through a network of VPA Participating
Providers.
Any of the following:

• Change in prescription of 0.50 diopter or more;
• Shift in axis of astigmatism of 15 degrees;
Vision Prescription • Difference in vertical prism greater than 1 prism
Change diopter; or
• Change in lens type (for example, contact lenses to
eyeglasses or single vision eyeglass lenses to bifocal
eyeglass lenses).
VPA Participating A provider who has an agreement in effect with the VPA for
Provider the provision of pediatric vision Benefits under this plan.
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127
Notices about your plan
Notice about plan Benefits: Benefits are only available for services and supplies you
receive while covered by this plan. You do not have the right to receive the Benefits of
this plan after coverage ends, except as provided under the Continuity of care section
when applicable. Blue Shield may change Benefits during the term of coverage as
specifically stated in this Agreement. Benefit changes, including any reduction in
Benefits or elimination of Benefits, apply to services or supplies you receive on or after
the effective date of the change.
Notice about Out-of-Area Covered Health Care Services: This Blue Shield plan provides
limited coverage for health care services received outside of California. Out-of-Area
Covered Health Care Services are restricted to Emergency Services, Urgent Services,
and Out-of-Area Follow-up Care. No other services will be covered outside of California
unless prior authorized by Blue Shield. You will be financially responsible for any services
received outside of California that are not Out-of-Area Covered Health Care Services
or prior authorized by Blue Shield. You have other ways to access health care when you
are out of state. Your plan includes Teladoc, a service that enables you to call or video
chat with a Physician 24/7. Additionally, you have anytime access to healthcare
advice from a nurse via phone or your Blue Shield online account with NurseHelp 24/7.
Please see the Out-of-Area Services section for additional information. If you have
questions about this notice and your Benefits, please contact Customer Service.
Notice about Medical Necessity: Benefits are only available for services and supplies
that are Medically Necessary. Blue Shield reserves the right to review all claims to
determine if a service or supply is Medically Necessary. A Physician or other Health Care
Provider’s decision to prescribe, order, recommend, or approve a service or supply
does not, in itself, make it Medically Necessary.
Notice about Mental Health and Substance Use Disorder services: You have a right to
receive timely and geographically accessible Mental Health/Substance Use Disorder
(MH/SUD) services when you need them. If Blue Shield fails to arrange those services for
you with an appropriate provider who is in the health plan's network, the health plan
must cover and arrange needed services for you from an out-of-network provider. If
that happens, you do not have to pay anything other than your ordinary in-network
cost-sharing.
If you do not need the services urgently, your health plan must offer an appointment for
you that is no more than 10 business days from when you requested the services from
the health plan. If you urgently need the services, your health plan must offer you an
appointment within 48 hours of your request (if the health plan does not require prior
authorization for the appointment) or within 96 hours (if the health plan does require
prior authorization).
If your health plan does not arrange for you to receive services within these timeframes
and within geographic access standards, you can arrange to receive services from any
licensed provider, even if the provider is not in your health plan's network. To be
9705.
Notices about your plan 128
covered by your health plan, your first appointment with the provider must be within 90
calendar days of the date you first asked the plan for the MH/SUD services.
If you have questions about how to obtain MH/SUD services or are having difficulty
obtaining services you can: 1) call your health plan at the telephone number on the
back of your health plan identification card; 2) call the California Department of
Managed Care's Help Center at 1-888-466-2219; or 3) contact the California
Department of Managed Health Care through its website at www.healthhelp.ca.gov to
request assistance in obtaining MH/SUD services.
Notice about reproductive health services: Some Hospitals and providers do not
provide one or more of the following services that may be covered under your plan
and that you or your family member might need:
• Family planning;
• Contraceptive services, including emergency contraception;
• Sterilization, including tubal ligation at the time of labor and delivery;
• Infertility treatments; or
• Abortion.
You should obtain more information before you enroll. Call your prospective doctor,
medical group, independent practice association, or clinic, or contact Customer
Service to ensure that you can obtain the health care services you need.
Notice about Participating Providers: Blue Shield contracts with Hospitals and Physicians
to provide services to Members for specified rates. This contractual agreement may
include incentives to manage all services for Members in an appropriate manner
consistent with the Agreement. To learn more about this payment system, contact
Customer Service.
You may have access to Covered Services from providers that participate in certain
value-based programs with Blue Shield. Such programs may include, but are not limited
to, accountable care organizations, episode-based payments, patient centered
medical homes, and shared savings arrangements.
If you receive Covered Services from a provider who participates in such a program,
you will not be responsible for paying any of the provider incentives, risk-sharing, and/or
care coordination fees that may be a part of such an arrangement.
Notice about dental services: IMPORTANT: If you opt to receive dental services that are
not Covered Services under this plan, a Dental Provider may charge you his or her usual
and customary rate for those services. Prior to providing a patient with dental services
that are not a covered Benefit, the Dentist should provide to the patient a treatment
plan that includes each anticipated service to be provided and the estimated cost of
each service. If you would like more information, call dental customer service. To fully
understand your coverage, you may wish to carefully review this Agreement.
Notice about telehealth: You have the right to access your medical records. The
records of any services provided to you through a Third-Party Corporate Telehealth
Provider will be shared with your PCP, unless you object.
You can receive Covered Services on an in-person basis or via telehealth, if available,
from your PCP, treating specialist, or from another contracting individual health
9705.
professional, contracting clinic, or contracting health facility consistent with existing

timeliness and geographic access standards. See the Timely Access to Care section for
more information.
If your plan includes Covered Services from Non-Participating Providers, you can
receive the Covered Service either on an in-person basis or via telehealth.
Please see the Health care professionals and facilities section for additional information
Notice about Manifest MedEx participation: Blue Shield participates in the Manifest
MedEx health information exchange (HIE). Blue Shield makes its Members’ health
information available to Manifest MedEx for access by their authorized Health Care
Providers. Manifest MedEx is an independent, not-for-profit organization that maintains
a statewide database of electronic patient records that includes health information
contributed by doctors, health care facilities, health care service plans, and health
insurance companies. Authorized Health Care Providers may securely access their
patients’ health information through the Manifest MedEx HIE to support the provision of
care.
Manifest MedEx respects Members’ right to privacy and follows applicable state and
federal privacy laws. Manifest MedEx uses advanced security systems and modern
data encryption techniques to protect Members’ privacy and the security of their
personal information. The Manifest MedEx notice of privacy practices is posted on its
website at manifestmedex.org.
You have the right to direct Manifest MedEx not to share your health information with
your Health Care Providers. Although opting out of Manifest MedEx may limit your
Health Care Provider’s ability to quickly access important health care information about
you, your Blue Shield coverage will not be affected by an election to opt-out of
Manifest MedEx. No doctor or Hospital participating in Manifest MedEx will deny
medical care to a patient who chooses not to participate in the Manifest MedEx HIE.
If you do not wish to have your health care information displayed in Manifest MedEx,
you should fill out the online form at manifestmedex.org/opt-out or call Manifest MedEx
at (888) 510-7142.
Notice about organ and tissue donation: Thousands of people in the United States need
an organ or tissue transplant. Each person on the transplant waiting list faces death
while waiting for an available organ or tissue.
Many Californians are eligible to become organ and tissue donors. To learn more about
organ and tissue donation, or to register as a donor, visit Donor Network West
(donornetworkwest.org) or Donate Life California (donatelifecalifornia.org). You may
also call the nearest city’s regional organ procurement agency for additional
information.
Notice about confidentiality of personal and health information: Blue Shield protects the
privacy of individually-identifiable personal information, including protected health
information. Individually-identifiable personal information includes health, financial,
and/or demographic information - such as name, address, and Social Security number.
Blue Shield will not disclose this information without authorization, except as permitted or
required by state or federal law.
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A STATEMENT DESCRIBING BLUE SHIELD’S POLICIES AND PROCEDURES FOR PRESERVING

THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO
YOU UPON REQUEST.
Blue Shield’s “Notice of Privacy Practices” can be obtained either by calling Customer
Service or by visiting blueshieldca.com.
Members who are concerned that Blue Shield may have violated their privacy rights, or
who disagree with a decision Blue Shield made about access to their individually-
identifiable personal information, may contact Blue Shield at:
Blue Shield of California Privacy Office
P.O. Box 272540
Chico, CA 95927-2540
Notice about confidential communication requests: A health plan shall notify
Subscribers and enrollees that they may request a confidential communication
pursuant to the following and how to make the request.
A health plan shall permit Subscribers and enrollees to request, and shall
accommodate requests for, confidential communication in the form and format
requested by the individual, if it is readily producible in the requested form and format,
or at alternative locations.
A health plan may require the Subscriber or enrollee to make a request for a
confidential communication in writing or by electronic transmission.
The confidential communication request shall be valid until the Subscriber or enrollee
submits a revocation of the request or a new confidential communication request is
submitted.
The confidential communication request shall apply to all communications that disclose
medical information or provider name and address related to receipt of medical
services by the individual requesting the confidential communication.
A confidential communication request may be submitted in writing to Blue Shield of
California at the mailing address, email address, or fax number at the bottom of this
page. A confidential communication form, available by going to
blueshieldca.com/privacy and clicking on “privacy forms,” may be used when
submitting a confidential communication request in writing, but it is not required.
Once in place, a valid confidential communication request prevents Blue Shield from:
1. Requiring the protected individual to obtain the primary Subscriber’s or other
enrollee’s authorization to receive sensitive services or submit a claim for sensitive
services if the protected individual has the right to consent to care; and 2. Disclosing
medical information relating to sensitive health services provided to a protected
individual to the primary Subscriber or any plan enrollees other than the protected
individual receiving care, absent an express written authorization of the protected
individual receiving care.
You may return this completed and signed form via any of these options:
Mail: Blue Shield of California Privacy Office, P.O. Box 272540, Chico CA, 95927-2540
Email: [email protected]
Fax: 1-800-201-9020
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132
Pediatric dental Benefits table
The table below outlines the pediatric dental Benefits covered by this plan by dental
procedure code. Pediatric Dental Benefits are subject to conditions, limitations, and
exclusions. See the Pediatric dental exclusions and Pediatric dental limitations sections
for more information.
Code Description Limitation
Diagnostic Procedures (D0100-D0999)
D0120 Periodic oral evaluation – Once every six months, per provider or after six months
established patient have elapsed following comprehensive oral evaluation
(D0150), same provider.
D0140 Limited oral evaluation – Once per Member per provider.

problem focused
D0145 Oral evaluation for a patient

under three years of age and
counseling with primary
caregiver
D0150 Comprehensive oral Once per Member per provider for the initial evaluation.
evaluation – new or
established patient
D0160 Detailed and extensive oral Once per Member per provider.
evaluation – problem
focused, by report
D0170 Re-evaluation – limited, A Benefit for the ongoing symptomatic care of

problem focused (established temporomandibular joint dysfunction:
patient; not post- operative
visit) • Up to six times in a three-month period; and
• Up to a maximum of 12 in a 12-month period.
D0171 Re-evaluation – post-

operative office visit
D0180 Comprehensive periodontal

evaluation – new or
established patient
D0190 Screening of a patient Not a Benefit.
D0191 Assessment of a patient Not a Benefit.
D0210 Intraoral – comprehensive Once per provider every 36 months.

series of radiographic images
D0220 Intraoral – periapical first Up to a maximum of 20 periapicals in a 12- month period

radiographic image by the same provider, in any combination of the following:
intraoral- periapical first radiographic image (D0220) and
intraoral- periapical each additional radiographic image
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Pediatric dental Benefits table 133

(D0230). Periapicals taken as part of an intraoral-complete
series of radiographic images (D0210) are not considered
against the maximum of 20 periapicals in a 12-month
period.
D0230 Intraoral – periapical each Up to a maximum of 20 periapicals in a 12-month period to

additional radiographic the same provider, in any combination of the following:
image intraoral- periapical first radiographic image (D0220) and
intraoral- periapical each additional radiographic image
(D0230). Periapicals taken as part of an intraoral complete
series of radiographic images (D0210) are not considered
against the maximum of 20 periapical films in a 12-month
period.
D0240 Intraoral – occlusal Up to a maximum of two in a six-month period per

radiographic image provider.
D0250 Extra-oral – 2D projection Once per date of service.

radiographic image created
using a stationary radiation
source, and detector
D0251 Extra-oral posterior dental Up to a maximum of four on the same date of service.
radiographic image
D0270 Bitewing – single radiographic Once per date of service. Not a Benefit for a totally
image edentulous area.
D0272 Bitewings – 2 radiographic Once every six months per provider.

images
Not a Benefit:
• Within 6 months of intraoral complete series of

radiographic images (D0210), same provider; and
• For a totally edentulous area.
D0273 Bitewings – 3 radiographic

images
D0274 Bitewings – 4 radiographic Once every six months per provider.

images
Not a Benefit:
• Within six months of intraoral-complete series of

radiographic images (D0210), same provider;
• For Members under the age of 10; and
• For a totally edentulous area.
D0277 Vertical bitewings - 7 to 8

radiographic images
D0310 Sialography
D0320 Temporomandibular joint Limited to the survey of trauma or pathology, up to a

arthrogram, including maximum of three per date of service.
injection
9705.
D0322 Tomographic survey Up to twice in a 12-month period per provider.
D0330 Panoramic radiographic Once in a 36-month period per provider, except when
image documented as essential for a follow-up/ post-operative
exam (such as after oral surgery).
D0340 2D cephalometric Twice in a 12-month period per provider.

radiographic image –
acquisition, measurement,
and analysis
D0350 2D oral/facial photographic Up to a maximum of four per date of service.

image obtained intra-orally or
extra-orally
D0396 3D printing of a 3D dental

surface scan
D0419 Assessment of salivary flow by Not a Benefit.

measurement
D0431 Adjunctive pre-diagnostic test Not a Benefit.

that aids in detection of
mucosal abnormalities
including premalignant and
malignant lesions, not to
include cytology or biopsy
procedures
D0460 Pulp vitality tests
D0470 Diagnostic casts Once per provider unless special circumstances are
documented (such as trauma or pathology which has
affected the course of orthodontic treatment); for
permanent dentition (unless over the age of 13 with
primary teeth still present or has a cleft palate or
craniofacial anomaly); and when provided by a certified
orthodontist.
D0502 Other oral pathology Must be provided by a certified oral pathologist.

procedures, by report
D0601 Caries risk assessment and

documentation, with a finding
of low risk

of moderate risk

of high risk
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D0701 Panoramic radiographic

image – image capture only
D0702 2-D cephalometric

radiographic image – image
capture only
D0703 2-D oral/facial photographic

image obtained intra-orally or
extra-orally – image capture
only
D0705 Extra-oral posterior dental

capture only
D0706 Intraoral – occlusal

capture only
D0707 Intraoral – periapical

capture only
D0708 Intraoral – bitewing

capture only
D0709 Intraoral – comprehensive

series of radiographic images
– image capture only
D0801 3D dental surface scan –

direct
D0802 3D dental surface scan –

indirect
D0803 3D facial surface scan – direct
D0804 3D facial surface scan –

indirect
D0999 Unspecified diagnostic

procedure, by report
Preventive Procedures (D1000-D1999)
D1110 Prophylaxis – adult
D1120 Prophylaxis – child Once in a six-month period.
D1206 Topical application of fluoride Once in a six-month period.

varnish
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D1208 Topical application of fluoride Once in a six-month period.

– excluding varnish
D1310 Nutritional counseling for

control of dental disease
D1320 Tobacco counseling for the

control and prevention of oral
disease
D1321 Counseling for the control

and prevention of adverse
oral, behavioral, and systemic
health effects associated with
high-risk substance use
D1330 Oral hygiene instructions
D1351 Sealant – per tooth Limited to the first, second and third permanent molars
that occupy the second molar position; only on the
occlusal surfaces that are free of decay and/or
restorations; and once per tooth every 36 months per
provider regardless of surfaces sealed.
D1352 Preventive resin restoration in Limited to the for first, second and third permanent molars
a moderate to high caries risk that occupy the second molar position; for an active
patient - permanent tooth cavitated lesion in a pit or fissure that does not cross the
dentinoenamel junction (DEJ); and once per tooth every
36 months per provider regardless of surfaces sealed.
D1353 Sealant repair – per tooth
D1354 Interim caries arresting

medicament application - per
tooth
D1355 Caries preventive

medicament application –
per tooth
D1510 Space maintainer – fixed – Once per quadrant per Member, for Members under the
unilateral – per quadrant age of 18 and only to maintain the space for a single
tooth.
D1516 Space maintainer – fixed – Once per arch when there is a missing primary molar in
bilateral, maxillary both quadrants or when there are two missing primary
molars in the same quadrant for Members under the age
of 18.
Not a Benefit:
• When the permanent tooth is near eruption or is

missing;
• For upper and lower anterior teeth; and
9705.

• For orthodontic appliances, tooth guidance
appliances, minor tooth movement, or activating
wires.
D1517 Space maintainer – fixed – Once per arch when there is a missing primary molar in
bilateral, mandibular both quadrants or when there are two missing primary
molars in the same quadrant for Members under the age
of 18.
Not a Benefit:

missing;
wires.
D1520 Space maintainer – Once per quadrant per Member, for Members under the
removable – unilateral – per age of 18 and only to maintain the space for a single
quadrant tooth.
Not a Benefit:

missing;
wires.
D1526 Space maintainer – Once per arch when there is a missing primary molar in
removable – bilateral, both quadrants or when there are two missing primary
maxillary molars in the same quadrant for Members under the age
of 18.
Not a Benefit:

missing;
wires.
D1527 Space maintainer – Once per arch when there is a missing primary molar in
removable – bilateral, both quadrants or when there are two missing primary
mandibular molars in the same quadrant for Members under the age
of 18.
Not a Benefit:

missing;
wires.
9705.
D1551 Re-cement or re-bond Once per provider, per applicable quadrant or arch for
bilateral space maintainer – Members under the age of 18.
maxillary
bilateral space maintainer – Members under the age of 18.
mandibular
unilateral space maintainer – Members under the age of 18.
per quadrant
D1556 Removal of fixed unilateral Not a Benefit to the original provider who placed the
space maintainer – per space maintainer.
quadrant
D1557 Removal of fixed bilateral Not a Benefit to the original provider who placed the
space maintainer – maxillary space maintainer.
D1558 Removal of fixed bilateral Not a Benefit to the original provider who placed the
space maintainer – space maintainer.
mandibular
D1575 Distal shoe space maintainer

– fixed – unilateral – per
quadrant
Restorative Procedures (D2000-D2999)
D2140 Amalgam – one surface, Once in a 12-month period for primary teeth and once in a
primary or permanent 36-month period for permanent teeth.
D2150 Amalgam – two surfaces, Once in a 12-month period for primary teeth and once in a
D2160 Amalgam – three surfaces, Once in a 12-month period for primary teeth and once in a
D2161 Amalgam – four or more Once in a 12-month period for primary teeth and once in a
surfaces, primary or 36-month period for permanent teeth.
permanent
D2330 Resin-based composite – one Once in a 12-month period for primary teeth and once in a
surface, anterior 36-month period for permanent teeth.
D2331 Resin-based composite – two Once in a 12-month period for primary teeth and once in a
surfaces, anterior 36-month period for permanent teeth.
D2332 Resin-based composite – Once in a 12-month period for primary teeth and once in a
three surfaces, anterior 36-month period for permanent teeth.
D2335 Resin-based composite – four Once in a 12-month period for primary teeth and once in a
or more surfaces (anterior) 36-month period for permanent teeth.
9705.
D2390 Resin-based composite Once in a 12-month period for primary teeth and once in a
crown, anterior 36-month period for permanent teeth.
D2391 Resin-based composite – one Once in a 12-month period for primary teeth and once in a
surface, posterior 36-month period for permanent teeth.
D2392 Resin-based composite – two Once in a 12-month period for primary teeth and once in a
surfaces, posterior 36-month period for permanent teeth.
D2393 Resin-based composite – Once in a 12-month period for primary teeth and once in a
three surfaces, posterior 36-month period for permanent teeth.
D2394 Resin-based composite – four Once in a 12-month period for primary teeth and once in a
or more surfaces, posterior 36-month period for permanent teeth.
D2542 Onlay - metallic – 2 surfaces Not a Benefit.
D2543 Onlay - metallic – 3 surfaces Not a Benefit.
D2544 Onlay - metallic – 4 or more Not a Benefit.

surfaces
D2642 Onlay - porcelain/ceramic – 2 Not a Benefit.

surfaces

surfaces

or more surfaces
D2662 Onlay - resin-based Not a Benefit.

composite – 2 surfaces

composite – 3 surfaces

composite – 4 or more
surfaces
D2710 Crown – resin - based Permanent anterior teeth and permanent posterior teeth
composite (indirect) (ages 13 or older):
Once in a five-year period and for any resin based
composite crown that is indirectly fabricated.
Not a Benefit:
• For third molars, unless the third molar occupies the first
or second molar position or is an abutment for an
existing removable partial denture with cast clasps or
rests; and
• For use as a temporary crown.
9705.
D2712 Crown – 3/4 resin-based Permanent anterior teeth and permanent posterior teeth
composite (indirect) (ages 13 or older):
Once in a five-year period and for any resin based
composite crown that is indirectly fabricated.
Not a Benefit:
existing removable partial denture with cast clasps or
rests; and
• For use as a temporary crown.
D2720 Crown – resin with high noble Not a Benefit.

metal
D2721 Crown – resin with Permanent anterior teeth and permanent posterior teeth
predominantly base metal (ages 13 or older):
Once in a five-year period.
Not a Benefit:
For third molars, unless the third molar occupies the first or
second molar position or is an abutment for an existing
removable partial denture with cast clasps or rests.
D2722 Crown – resin with noble Not a Benefit.

metal
D2740 Crown – porcelain/ceramic Permanent anterior teeth and permanent posterior teeth
(ages 13 or older):
Not a Benefit:
D2750 Crown – porcelain fused to Not a Benefit.

high noble metal
D2751 Crown – porcelain fused to Permanent anterior teeth and permanent posterior teeth
Not a Benefit:

noble metal
9705.

titanium and titanium alloys
D2780 Crown – 3/4 cast high noble Not a Benefit.

metal
D2781 Crown – 3/4 cast Permanent anterior teeth and permanent posterior teeth
Not a Benefit:
D2782 Crown - 3/4 cast noble metal Not a Benefit.
D2783 Crown – 3/4 porcelain/ Permanent anterior teeth and permanent posterior teeth
ceramic (ages 13 or older):
Not a Benefit:
D2790 Crown – full cast high noble Not a Benefit.

metal
D2791 Crown – full cast Permanent anterior teeth and permanent posterior teeth
Once in a five-year period; for permanent anterior teeth
only; for Members 13 or older only.
Not a Benefit:
D2792 Crown – full cast noble metal Not a Benefit.
D2794 Crown – titanium and titanium Not a Benefit.

alloys
D2910 Re-cement or re-bond inlay, Once in a 12-month period, per provider.

onlay, veneer, or partial
coverage restoration
D2915 Re-cement or re-bond

indirectly fabricated or
prefabricated post and core
9705.
D2920 Re-cement or re-bond crown The original provider is responsible for all re-cementations
within the first 12 months following the initial placement of
prefabricated or laboratory processed crowns. Not a
Benefit within 12 months of a previous re-cementation by
the same provider.
D2921 Reattachment of tooth

fragment, incisal edge, or
cusp
D2928 Prefabricated Once in a 12-month period.

porcelain/ceramic crown –
permanent tooth
D2929 Prefabricated Once in a 12-month period.

porcelain/ceramic crown -
primary tooth
D2930 Prefabricated stainless-steel Once in a 12-month period.

crown – primary tooth
D2931 Prefabricated stainless-steel Once in a 36-month period. Not a Benefit for third molars,
crown – permanent tooth unless the third molar occupies the 1st or 2nd molar
position.
D2932 Prefabricated resin crown Once in a 12-month period for primary teeth and once in a
36-month period for permanent teeth. Not a Benefit for
third molars, unless the third molar occupies the first or 2nd
molar position.
D2933 Prefabricated stainless-steel Once in a 12-month period for primary teeth and once in a
crown with resin window 36-month period for permanent teeth. Not a Benefit for
third molars, unless the third molar occupies the first or
second molar position.
D2940 Protective restoration Once per tooth in a six-month period, per provider.
Not a Benefit:
• When performed on the same date of service with a

permanent restoration or crown, for same tooth; and
• On root canal treated teeth.
D2941 Interim therapeutic restoration

– primary dentition
D2949 Restorative foundation for an

indirect restoration
D2950 Core buildup, including any

pins when required
D2951 Pin retention – per tooth, in For permanent teeth only; when performed on the same
addition to restoration date of service with an amalgam or composite; once per
tooth regardless of the number of pins placed; for a
9705.

posterior restoration when the destruction involves three or
more connected surfaces and at least one cusp; or, for an
anterior restoration when extensive coronal destruction
involves the incisal angle.
D2952 Post and core in addition to Once per tooth regardless of number of posts placed and
crown, indirectly fabricated only in conjunction with allowable crowns (prefabricated
or laboratory processed) on root canal treated permanent
teeth.
D2953 Each additional indirectly

fabricated post – same tooth
D2954 Prefabricated post and core Once per tooth regardless of number of posts placed and
in addition to crown only in conjunction with allowable crowns (prefabricated
or laboratory processed) on root canal treated permanent
teeth.
D2955 Post removal
D2957 Each additional

prefabricated post - same
tooth
D2971 Additional procedures to

customize a crown to fit under
an existing partial denture
framework
D2976 Band stabilization – per tooth
D2980 Crown repair, necessitated by Limited to laboratory processed crowns on permanent

restorative material failure teeth. Not a Benefit within 12 months of initial crown
placement or previous repair for the same provider.
D2989 Excavation of a tooth resulting

in the determination of non-
restorability
D2991 Application of hydroxyapatite

regeneration medicament –
per tooth
D2999 Unspecified restorative

Endodontics Procedures (D3000-D3999)
D3110 Pulp cap – direct (excluding

final restoration)
D3120 Pulp cap – indirect (excluding

final restoration)
9705.
D3220 Therapeutic pulpotomy Once per primary tooth.

(excluding final restoration) –
Not a Benefit:
removal of pulp coronal to
the dentinocemental junction • For a primary tooth near exfoliation;
and application of • For a primary tooth with a necrotic pulp or a periapical
medicament lesion;
• For a primary tooth that is non-restorable; and d. for a
permanent tooth.
D3221 Pulpal debridement, primary Once per permanent tooth; over-retained primary teeth
and permanent teeth with no permanent successor. Not a Benefit on the same
date of service with any additional services, same tooth.
D3222 Partial pulpotomy for Once per permanent tooth.

apexogenesis - permanent
Not a Benefit:
tooth with incomplete root
development • For primary teeth;
existing fixed partial denture or removable partial
denture with cast clasps or rests; and
• On the same date of service as any other endodontic
procedures for the same tooth.
D3230 Pulpal therapy (resorbable Once per primary tooth.

filling) – anterior, primary tooth
Not a Benefit:
(excluding final restoration)
• For a primary tooth near exfoliation;
• With a therapeutic pulpotomy (excluding final
restoration) (D3220), same date of service, same tooth;
and
• With pulpal debridement, primary and permanent
teeth (D3221), same date of service, same tooth.
D3240 Pulpal therapy (resorbable Once per primary tooth.

filling) – posterior, primary
Not a Benefit:
tooth (excluding final
restoration) • For a primary tooth near exfoliation;
• With a therapeutic pulpotomy (excluding final
restoration) (D3220), same date of service, same tooth;
and
• With pulpal debridement, primary and permanent
teeth (D3221), same date of service, same tooth.
D3310 Endodontic therapy, anterior Once per tooth for initial root canal therapy treatment.
restoration)
D3320 Endodontic therapy, premolar Once per tooth for initial root canal therapy treatment.
restoration)
9705.
D3330 Endodontic therapy, molar Once per tooth for initial root canal therapy treatment. Not
tooth (excluding final a Benefit for third molars, unless the third molar occupies
restoration) the first or second molar position or is an abutment for an
existing fixed partial denture or removable partial denture
with cast clasps or rests.
D3331 Treatment of root canal

obstruction; non-surgical
access
D3333 Internal root repair of

perforation defects
D3346 Retreatment of previous root Once per tooth after more than 12 months has elapsed
canal therapy – anterior from initial treatment.
canal therapy – premolar from initial treatment.
canal therapy – molar from initial treatment. Not a Benefit for third molars, unless
the third molar occupies the first or second molar position
or is an abutment for an existing fixed partial denture or
D3351 Apexification/recalcification - Once per permanent tooth.

initial visit (apical
Not a Benefit:
closure/calcific repair of
perforations, root resorption, • For primary teeth;
etc.) • For third molars, unless the third molar occupies the first
D3352 Apexification/recalcification - Once per permanent tooth and only following

interim medication apexification/ recalcification initial visit (apical closure/
replacement calcific repair of perforations, root resorption, etc.) (D3351).
Not a Benefit:
• For primary teeth;

D3353 Apexification/recalcification - Not a Benefit.

final visit (includes completed
root canal therapy - apical
closure/calcific repair of
9705.

perforations, root resorption,
etc.)
D3410 Apicoectomy – anterior For permanent anterior teeth only; must be performed
after more than 90 days from a root canal therapy has
elapsed except when medical necessity is documented or
after more than 24 months of a prior
apicoectomy/periradicular surgery has elapsed.
D3421 Apicoectomy – premolar (first For permanent bicuspid teeth only; must be performed
root) after more than 90 days from a root canal therapy has
elapsed except when medical necessity is documented,
after more than 24 months of a prior
apicoectomy/periradicular surgery has elapsed. Not a
Benefit for third molars, unless the third molar occupies the
first or second molar position or is an abutment for an
existing fixed partial denture or removable partial denture
with cast clasps or rests.
D3425 Apicoectomy – molar (first For permanent first and second molar teeth only; must be
root) performed after more than 90 days from a root canal
therapy has elapsed except when medical necessity is
documented or after more than 24 months of a prior
apicoectomy/periradicular surgery has elapsed. Not a
Benefit for 3rd molars, unless the 3rd molar occupies the 1st
or 2nd molar position or is an abutment for an existing fixed
partial denture or removable partial denture with cast
clasps or rests.
D3426 Apicoectomy – (each For permanent teeth only; must be performed after more
additional root) than 90 days from a root canal therapy has elapsed
except when medical necessity is documented or after
more than 24 months of a prior apicoectomy/periradicular
surgery has elapsed.
D3428 Bone graft in conjunction with

periradicular surgery – per
tooth, single site
D3429 Bone graft in conjunction with

periradicular surgery – each
additional contiguous tooth in
the same surgical site
D3430 Retrograde filling – per root
D3431 Biologic materials to aid in soft

and osseous tissue
regeneration, in conjunction
with periradicular surgery
D3432 Guided tissue regeneration, Not a Benefit.

resorbable barrier, per site, in
conjunction with periradicular
surgery
9705.
D3450 Root amputation – per root Not a Benefit.
D3471 Surgical repair of root

resorption – anterior

resorption premolar

resorption – molar
D3910 Surgical procedure for

isolation of tooth with rubber
dam
D3920 Hemisection (including any Not a Benefit.

root removal), not including
root canal therapy
D3950 Canal preparation and fitting Not a Benefit.

of preformed dowel or post
D3999 Unspecified endodontic

Periodontics Procedures (D4000-D4999)
D4210 Gingivectomy or Once per quadrant every 36 months and limited to

gingivoplasty – four or more Members age 13 or older.
contiguous teeth or tooth
bounded spaces per
quadrant
D4211 Gingivectomy or Once per quadrant every 36 months and limited to

gingivoplasty – one to three Members age 13 or older.
contiguous teeth or tooth
bounded spaces per
quadrant
D4240 Gingival flap procedure, Not a Benefit.

including root planing - four or
more contiguous teeth or
tooth bounded spaces per
quadrant
D4241 Gingival flap procedure, Not a Benefit.

including root planing - one to
three contiguous teeth or
quadrant
D4249 Clinical crown lengthening – For Members age 13 or older.

hard tissue
9705.
D4260 Osseous surgery (including Once per quadrant every 36 months and limited to
elevation of a full thickness Members age 13 or older.
flap and closure) – four or
more contiguous teeth or
quadrant
D4261 Osseous surgery (including Once per quadrant every 36 months and limited to
elevation of a full thickness Members age 13 or older.
flap and closure) – one to
three contiguous teeth or
tooth bounded spaces, per
quadrant
D4263 Bone replacement graft – Not a Benefit.

retained natural tooth – first
site in quadrant
D4264 Bone replacement graft – Not a Benefit.

retained natural tooth – each
additional site in quadrant
D4265 Biologic materials to aid in soft For Members age 13 or older.

and osseous tissue
regeneration, per site

natural teeth - resorbable
barrier, per site

natural teeth – non-
resorbable barrier, per site
D4270 Pedicle soft tissue graft Not a Benefit.

procedure
D4273 Autogenous connective tissue Not a Benefit.

graft procedure (including
donor and recipient surgical
sites) first tooth, implant, or
edentulous tooth position in
graft
D4275 Non-autogenous connective Not a Benefit.

tissue graft procedure
(including recipient site and
donor material) – first tooth,
implant or edentulous tooth
position in same graft site
D4283 Autogenous connective tissue Not a Benefit.

graft procedure (including
donor and recipient surgical
sites) – each additional
9705.

contiguous tooth, implant or
edentulous tooth position in
same graft site
D4285 Non-autogenous connective Not a Benefit.

tissue graft procedure
(including recipient surgical
site and donor material) –
each additional contiguous
tooth, implant or edentulous
tooth position in same graft
site
D4286 Removal of non-resorbable Not a Benefit.

barrier
D4341 Periodontal scaling and root Once per quadrant every 24 months and limited to
planing – four or more teeth Members age 13 or older.
per quadrant
D4342 Periodontal scaling and root Once per quadrant every 24 months and limited to
planing – one to three teeth Members age 13 or older.
per quadrant
D4346 Scaling in presence of

generalized moderate or
severe gingival inflammation –
full mouth, after oral
evaluation
NOTE: This code is categorized
as Periodontal Maintenance
(Basic Services). For cost share
information, please refer to
the Basic Services category
rather than Major Services on
the Summary of Benefits.
D4355 Full mouth debridement to For Members age 13 or older.

enable a comprehensive
periodontal evaluation and
diagnosis on a subsequent
visit
D4381 Localized delivery of For Members age 13 or older.

antimicrobial agents via a
controlled release vehicle into
diseased crevicular tissue, per
tooth
D4910 Periodontal maintenance Once in a calendar quarter and only in the 24-month
period following the last periodontal scaling and root
NOTE: This code is categorized
planing (D4341-D4342). This procedure must be preceded
as Periodontal Maintenance
by a periodontal scaling and root planing and will be a
(Basic Services). For cost share
Benefit only after completion of all necessary scaling and
information, please refer to
root planing and only for Members residing in a Skilled
9705.

the Basic Services category Nursing Facility (SNF) or Intermediate Care Facility (ICF). Not
rather than Major Services on a Benefit in the same calendar quarter as scaling and root
the Summary of Benefits. planing.
D4920 Unscheduled dressing change Once per Member per provider; for Members age 13 or
(by someone other than older only; must be performed within 30 days of the date of
treating dentist or his or her service of gingivectomy or gingivoplasty (D4210 and
staff) D4211) and osseous surgery (D4260 and D4261).
D4999 Unspecified periodontal For Members age 13 or older.

Prosthodontics, removable Procedures (D5000-D5899)
D5110 Complete denture – maxillary Once in a five-year period from a previous complete,
immediate or overdenture- complete denture. A
laboratory reline (D5750) or chairside reline (D5730) is a
Benefit 12 months after the date of service for this
procedure.
D5120 Complete denture – Once in a five-year period from a previous complete,

mandibular immediate or overdenture- complete denture. A
laboratory reline (D5751) or chairside reline (D5731) is a
Benefit 12 months after the date of service for this
procedure.
D5130 Immediate denture – maxillary Once per Member. Not a Benefit as a temporary denture.
Subsequent complete dentures are not a Benefit within a
five-year period of an immediate denture. A laboratory
reline (D5750) or chairside reline (D5730) is a Benefit six
months after the date of service for this procedure.
D5140 Immediate denture – Once per Member. Not a Benefit as a temporary denture.
mandibular Subsequent complete dentures are not a Benefit within a
five-year period of an immediate denture.
D5211 Maxillary partial denture - resin

base (including any
conventional clasps, rests and
teeth)
D5212 Mandibular partial denture -

resin base (including any
conventional clasps, rests and
teeth)
D5213 Maxillary partial denture - cast

metal framework with resin
denture bases (including
retentive/clasping materials,
rests and teeth)
D5214 Mandibular partial denture -

cast metal framework with
resin denture bases (including
9705.

rests and teeth)
D5221 Immediate maxillary partial Once in a five-year period and when replacing a
denture - resin base (including permanent anterior tooth/ teeth and/or the arch lacks
retentive/clasping materials, posterior balanced occlusion. Lack of posterior balanced
rests and teeth) occlusion is defined as follows:
• Five posterior permanent teeth are missing, (excluding

third molars);
• All four first and second permanent molars are missing;
or
• The first and second permanent molars and second
bicuspid are missing on the same side.
Not a Benefit for replacing missing third molars.
Includes limited follow-up care only; does not include
future rebasing / relining procedures.
D5222 Immediate mandibular partial Once in a five-year period and when replacing a
denture – resin base permanent anterior tooth/teeth and/or the arch lacks
(including retentive/clasping posterior balanced occlusion. Lack of posterior balanced
materials, rests and teeth) occlusion is defined as follows:
• Five posterior permanent teeth are missing, (excluding

third molars);
or
D5223 Immediate maxillary partial Once in a five-year period and when opposing a full
denture – cast metal denture and the arch lacks posterior balanced occlusion.
framework with resin denture Lack of posterior balanced occlusion is defined as follows:
bases (including
retentive/clasping materials, • Five posterior permanent teeth are missing, (excluding
rests and teeth) third molars);
or
D5224 Immediate mandibular partial Once in a five-year period and when opposing a full
denture – cast metal denture and the arch lacks posterior balanced occlusion.
framework with resin denture Lack of posterior balanced occlusion is defined as follows:
bases (including
retentive/clasping materials, • Five posterior permanent teeth are missing, (excluding
rests and teeth) third molars);
9705.

or
D5225 Maxillary partial denture – Not a Benefit.

flexible base (including
rests, and teeth)
D5226 Mandibular partial denture – Not a Benefit.

flexible base (including
rests, and teeth)
D5227 Immediate maxillary partial Not a Benefit.

denture – flexible base
(including any clasps, rests
and teeth)
D5228 Immediate mandibular partial Not a Benefit.

denture – flexible base
(including any clasps, rests
and teeth)
D5282 Removable unilateral partial Not a Benefit.

denture – one piece cast
metal (including
rests, and teeth), maxillary

denture – one piece cast
metal (including
rests, and teeth), mandibular

denture – one piece flexible
base (including
rests, and teeth), per
quadrant

denture – one piece resin
(including retentive/clasping
materials, rests, and teeth),
per quadrant
9705.
D5410 Adjust complete denture – Once per date of service per provider and no more than
maxillary twice in a 12-month period per provider.
Not a Benefit:
• Same date of service or within six months of the date

of service of a complete denture- maxillary (D5110),
immediate denture- maxillary (D5130)or overdenture-
complete (D5863 & D5865);
of service of a reline complete maxillary denture
(chairside) (D5730), reline complete maxillary denture
(laboratory) (D5750) and tissue conditioning, maxillary
(D5850); and
of service of repair broken complete denture base
(D5511 & D5512) and replace missing or broken teeth
complete denture (D5520).
D5411 Adjust complete denture – Once per date of service per provider and no more than
mandibular twice in a 12-month period per provider.
Not a Benefit:

of service of a complete denture- mandibular (D5120),
immediate denture- mandibular (D5140) or
overdenture-complete (D5863 & D5865);
of service of a reline complete mandibular denture
(chairside) (D5731), reline complete mandibular
denture (laboratory) (D5751) and tissue conditioning,
mandibular (D5851); and
of service of repair broken complete denture base
(D5511 & D5512) and replace missing or broken teeth
complete denture (D5520).
D5421 Adjust partial denture – Once per date of service per provider and no more than
maxillary twice in a 12-month period per provider.
Not a Benefit:

of service of a maxillary partial resin base (5211) or
maxillary partial denture cast metal framework with
resin denture bases (D5213);
of service of a reline maxillary partial denture
(chairside) (D5740), reline maxillary partial denture
(laboratory) (D5760) and tissue conditioning, maxillary
(D5850); and
of service of repair resin denture base (D5611 &
D5612), repair cast framework (D5621 & D5622), repair
or replace broken clasp (D5630), replace broken teeth
per tooth (D5640), add tooth to existing partial denture
9705.

(D5650) and add clasp to existing partial denture
(D5660).
D5422 Adjust partial denture – Once per date of service per provider and no more than
mandibular twice in a 12-month period per provider.
Not a Benefit:

of service of a mandibular partial- resin base (D5212) or
mandibular partial denture- cast metal framework with
resin denture bases (D5214);
of service of a reline mandibular partial denture
(chairside) (D5741), reline mandibular partial denture
(laboratory) (D5761) and tissue conditioning,
mandibular (D5851); and
• Same date of service or within 6 months of the date of
service of repair resin denture base (D5611 & D5612),
repair cast framework (D5621 & D5622), repair or
replace broken clasp (D5630), replace broken teeth
per tooth (D5640), add tooth to existing partial denture
(D5650) and add clasp to existing partial denture
(D5660).
D5511 Repair broken complete Once per date of service per provider and no more than
denture base, mandibular twice in a 12 month period per provider. Not a Benefit on
the same date of service as reline complete maxillary
denture (chairside) (D5730), reline complete mandibular
denture (chairside) (D5731), reline complete maxillary
denture (laboratory) (D5750) and reline complete
mandibular denture (laboratory) (D5751).
D5512 Repair broken complete Once per date of service per provider and no more than
denture base, maxillary twice in a 12 month period per provider. Not a Benefit on
the same date of service as reline complete maxillary
denture (chairside) (D5730), reline complete mandibular
denture (laboratory) (D5750) and reline complete
mandibular denture (laboratory) (D5751).
D5520 Replace missing or broken Up to a maximum of four, per arch, per date of service per
teeth – complete denture provider and no more than twice per arch, in a 12-month
(each tooth) period per provider.
D5611 Repair resin denture base, Once per date of service per provider; no more than twice
mandibular in a 12 month period per provider; and for partial dentures
only. Not a Benefit same date of service as reline maxillary
partial denture (chairside) (D5740), reline mandibular
partial denture (chairside) (D5741), reline maxillary partial
denture (laboratory) (D5760) and reline mandibular partial
denture (laboratory) (D5761).
D5612 Repair resin denture base, Once per date of service per provider; no more than twice
maxillary in a 12 month period per provider; and for partial dentures
only. Not a Benefit same date of service as reline maxillary
9705.

partial denture (chairside) (D5740), reline mandibular
partial denture (chairside) (D5741), reline maxillary partial
denture (laboratory) (D5760) and reline mandibular partial
denture (laboratory) (D5761).
D5621 Repair cast framework, Once per date of service per provider and no more than
mandibular twice in a 12 month period per provider.
D5622 Repair cast framework, Once per date of service per provider and no more than
maxillary twice in a 12 month period per provider.
D5630 Repair or replace broken Up to a maximum of three, per date of service per provider
clasp – per tooth and no more than twice per arch, in a 12-month period
per provider.
D5640 Replace broken teeth – per Up to a maximum of four, per arch, per date of service per
tooth provider; no more than twice per arch, in a 12-month
period per provider; and for partial dentures only.
D5650 Add tooth to existing partial Once per tooth and up to a maximum of three, per date
denture of service per provider. Not a Benefit for adding third
molars.
D5660 Add clasp to existing partial Up to a maximum of three, per date of service per provider
denture – per tooth and no more than twice per arch, in a 12-month period
per provider.
D5670 Replace all teeth and acrylic Not a Benefit.

on cast metal framework
(maxillary)
D5671 Replace all teeth and acrylic Not a Benefit.

on cast metal framework
(mandibular)
D5710 Rebase complete maxillary Not a Benefit.

denture
D5711 Rebase complete mandibular Not a Benefit.

denture
D5720 Rebase maxillary partial Not a Benefit.

denture
D5721 Rebase mandibular partial Not a Benefit.

denture
D5730 Reline complete maxillary Once in a 12-month period; six months after the date of
denture (chairside) service for an immediate denture-maxillary (D5130) or
immediate overdenture- complete (D5863 & D5865) that
required extractions; 12 months after the date of service for
a complete (remote) denture maxillary (D5110) or
overdenture (remote complete (D5863 & D5865) that did
9705.

not require extractions. Not a Benefit within 12 months of a
reline complete maxillary denture (laboratory) (D5750).
D5731 Reline complete mandibular Once in a 12-month period; six months after the date of
denture (chairside) service for an immediate denture-mandibular (D5140) or
required extractions; or 12 months after the date of service
for a complete (remote) denture- mandibular (D5120) or
overdenture (remote) complete (D5863 & D5865) that did
reline complete mandibular denture (laboratory) (D5751).
D5740 Reline maxillary partial Once in a 12-month period; six months after the date of
denture (chairside) service for maxillary partial denture-resin base (D5211) or
maxillary partial denture- cast metal framework with resin
denture bases (D5213) that required extractions; or 12
months after the date of service for maxillary partial
denture- resin base (D5211) or maxillary partial denture
cast metal framework with resin denture bases (D5213) that
did not require extractions. Not a Benefit within 12 months
of a reline maxillary partial denture (laboratory) (D5760).
D5741 Reline mandibular partial Once in a 12-month period; six months after the date of
denture (chairside) service for mandibular partial denture- resin base (D5212)
or mandibular partial denture- cast metal framework with
resin denture bases (D5214) that required extractions; or 12
months after the date of service for mandibular partial
denture resin base (D5212) or mandibular partial denture
cast metal framework with resin denture bases (D5214) that
did not require extractions. Not a Benefit within 12 months
of a reline mandibular partial denture (laboratory) (D5761).
D5750 Reline complete maxillary Once in a 12-month period; six months after the date of
denture (laboratory) service for an immediate denture- maxillary (D5130) or
for a complete (remote) denture- maxillary (D5110) or
reline complete maxillary denture (chairside) (D5730).
D5751 Reline complete mandibular Once in a 12-month period; six months after the date of
denture (laboratory) service for an immediate denture- mandibular (D5140) or
for a complete (remote) denture - mandibular (D5120) or
reline complete mandibular denture (chairside) (D5731).
D5760 Reline maxillary partial Once in a 12-month period and six months after the date
denture (laboratory) of service for maxillary partial denture cast metal
framework with resin denture bases (D5213) that required
extractions, or 12 months after the date of service for
9705.

maxillary partial denture cast metal framework with resin
denture bases (D5213) that did not require extractions.
Not a Benefit:
• Within 12 months of a reline maxillary partial denture

(chairside) (D5740); and
• For maxillary partial denture resin base (D5211).
D5761 Reline mandibular partial Once in a 12-month period; six months after the date of
denture (laboratory) service for mandibular partial denture- cast metal
framework with resin denture bases (D5214) that required
extractions; or 12 months after the date of service for
mandibular partial denture cast metal framework with resin
denture bases (D5214) that did not require extractions.
Not a Benefit:
• Within 12 months of a reline mandibular partial denture

(chairside) (D5741); and
• For a mandibular partial denture resin base (D5212).
D5850 Tissue conditioning, maxillary Twice per prosthesis in a 36-month period.

Not a Benefit:
• Same date of service as reline complete maxillary

denture (chairside) (D5730), reline maxillary partial
denture (laboratory) (D5750) and reline maxillary
partial denture (laboratory) (D5760); and
• Same date of service as a prosthesis that did not
require extractions.
D5851 Tissue conditioning, Twice per prosthesis in a 36-month period.

mandibular
Not a Benefit:
• Same date of service as reline complete mandibular

denture (chairside) (D5731), reline mandibular partial
denture (chairside) (D5741), reline complete
mandibular denture (laboratory) (D5751) and reline
mandibular partial denture (laboratory) (D5761); and
• Same date of service as a prosthesis that did not
require extractions.
D5862 Precision attachment, by

report
D5863 Overdenture – complete Once in a five-year period.

maxillary
D5864 Overdenture – partial Once in a five-year period.

maxillary
D5865 Overdenture – complete Once in a five-year period.

mandibular
9705.
D5866 Overdenture – partial Once in a five-year period.

mandibular
D5876 Add metal substructure to Not a Benefit.

acrylic full denture (per arch)
D5899 Unspecified removable

prosthodontic procedure, by
report
Maxillofacial Prosthetics Procedures (D5900-D5999)
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
D5916 Ocular prosthesis Not a Benefit on the same date of service as ocular
prosthesis, interim (D5923).
D5919 Facial prosthesis
D5922 Nasal septal prosthesis
D5923 Ocular prosthesis, interim Not a Benefit on the same date of service as ocular
D5924 Cranial prosthesis
D5925 Facial augmentation implant

prosthesis
D5926 Nasal prosthesis, replacement
D5927 Auricular prosthesis,

replacement
D5928 Orbital prosthesis,

replacement
D5929 Facial prosthesis, replacement
D5931 Obturator prosthesis, surgical Not a Benefit on the same date of service as obturator
prosthesis, definitive (D5932) and obturator prosthesis,
interim (D5936).
9705.
D5932 Obturator prosthesis, definitive Not a Benefit on the same date of service as obturator
prosthesis, surgical (D5931) and obturator prosthesis, interim
(D5936).
D5933 Obturator prosthesis, Twice in a 12-month period.

modification
Not a Benefit on the same date of service as obturator
prosthesis, surgical (D5931), obturator prosthesis, definitive
(D5932) and obturator prosthesis, interim (D5936).
D5934 Mandibular resection

prosthesis with guide flange
D5935 Mandibular resection

prosthesis without guide
flange
D5936 Obturator prosthesis, interim Not a Benefit on the same date of service as obturator
prosthesis, surgical (D5931) and obturator prosthesis,
definitive (D5932).
D5937 Trismus appliance (not for

TMD treatment)
D5951 Feeding aid For Members under the age of 18 only.
D5952 Speech aid prosthesis, For Members under the age of 18 only.
pediatric
D5953 Speech aid prosthesis, adult For Members under the age of 18 only.
D5954 Palatal augmentation

prosthesis
D5955 Palatal lift prosthesis, definitive Not a Benefit on the same date of service as palatal lift
D5958 Palatal lift prosthesis, interim Not a Benefit on the same date of service with palatal lift
prosthesis, definitive (D5955).
D5959 Palatal lift prosthesis, Twice in a 12-month period.

modification
Not a Benefit on the same date of service as palatal lift
prosthesis, definitive (D5955) and palatal lift prosthesis,
interim (D5958).
D5960 Speech aid prosthesis, Twice in a 12-month period.

modification
Not a Benefit on the same date of service as speech aid
prosthesis, pediatric (D5952) and speech aid prosthesis,
adult (D5953).
D5982 Surgical stent
D5983 Radiation carrier
9705.
D5984 Radiation shield
D5985 Radiation cone locator
D5986 Fluoride gel carrier A Benefit only in conjunction with radiation therapy
directed at the teeth, jaws or salivary glands.
D5987 Commissure splint
D5988 Surgical splint
D5991 Vesiculobullous disease

medicament carrier
D5999 Unspecified maxillofacial

prosthesis, by report
Implant Services Procedures (D6000-D6199)
D6010 Surgical placement of implant

body: endosteal implant
D6011 Surgical access to an implant

body (second stage implant
surgery)
D6012 Surgical placement of interim

implant body for transitional
prosthesis; endosteal implant
D6013 Surgical placement of mini

implant
D6040 Surgical placement: eposteal

implant
D6050 Surgical placement:

transosteal implant
D6055 Connecting bar - implant

supported or abutment
supported
D6056 Prefabricated abutment -

includes modification and
placement
D6057 Custom fabricated abutment

- includes placement
D6058 Abutment supported

porcelain/ceramic crown
9705.

porcelain fused to metal
crown (high noble metal)

crown (predominantly base
metal)

crown (noble metal)
D6062 Abutment supported cast

metal crown (high noble
metal)

metal crown (predominantly
base metal)

metal crown (noble metal)
D6065 Implant supported

porcelain/ceramic crown
D6066 Implant supported crown –

porcelain fused to high noble
alloys

high noble alloys
D6068 Abutment supported retainer

for porcelain/ceramic FPD

for porcelain fused to metal
FPD (high noble metal)

FPD (predominantly base
metal)

FPD (noble metal)

for cast metal FPD (high noble
metal)
9705.

for cast metal FPD
(predominantly base metal)

for cast metal FPD (noble
metal)
D6075 Implant supported retainer for

ceramic FPD
D6076 Implant supported retainer

FPD – porcelain fused to high
noble alloys

metal FPD – high noble alloys
D6080 Implant maintenance

procedures when prosthesis is
removed and reinserted,
including cleansing of
prosthesis and abutments
D6081 Scaling and debridement in

the presence of inflammation
or mucositis of a single
implant, including cleaning of
the implant surfaces, without
flap entry and closure

porcelain fused to
predominantly base alloys

porcelain fused to noble
alloys

porcelain fused to titanium
and titanium alloys
D6085 Interim implant crown


noble alloys

9705.
D6089 Accessing and retorquing

loose implant screw – per
screw
D6090 Repair implant supported

prosthesis, by report
D6091 Replacement of replaceable

part of semi-precision or
precision attachment of
implant/abutment supported
prosthesis, per attachment
D6092 Re-cement or re-bond Not a Benefit within 12 months of a previous recementation

implant/abutment supported by the same provider.
crown
D6093 Re-cement or re-bond Not a Benefit within 12 months of a previous recementation

implant/abutment supported by the same provider.
fixed partial denture
D6094 Abutment supported crown –

D6095 Repair implant abutment, by

report
D6096 Remove broken implant

retaining screw
D6097 Abutement supported crown

– porcelain fused to titanium
and titanium alloys
D6098 Implant supported retainer –

porcelain fused to

FPD – porcelain fused to
noble alloys
D6100 Surgical removal of implant

body
D6105 Removal of implant body not

requiring bone removal or
flap elevation
D6110 Implant/abutment supported

removable denture for
edentulous arch - maxillary
9705.

edentulous arch - mandibular

partially edentulous arch -
maxillary

partially edentulous arch -
mandibular

fixed denture for edentulous
arch - maxillary

fixed denture for edentulous
arch - mandibular

fixed denture for partially
edentulous arch - maxillary

fixed denture for partially
edentulous arch - mandibular

interim fixed denture for
edentulous arch – mandibular

interim fixed denture for
edentulous arch – maxillary
D6120 Implant supported retainer –

and titanium alloys

metal FPD – predominantly
base alloys

metal FPD – noble alloys

metal FPD – titanium and
titanium alloys
9705.
D6190 Radiographic/surgical implant

index, by report
D6191 Semi-precision abutment –

placement
D6192 Semi-precision attachment –

placement

crown for FPD – titanium and
titanium alloys
D6195 Abutement supported

retainer – porcelain fused to
D6197 Replacement of restorative

material used to close an
access opening of a screw-
retained implant supported
prosthesis, per implant
D6198 Remove interim implant

component
D6199 Unspecified implant

Prosthodontics, fixed Procedures (D6200-D6999)
D6205 Pontic – indirect resin based Not a Benefit.

composite
D6210 Pontic – cast high noble metal Not a Benefit.
D6211 Pontic – cast predominately Once in a five-year period; only when the criteria are met
base metal for a resin partial denture or cast partial denture (D5211,
D5212, D5213 and D5214); and only when billed on the
same date of service with fixed partial denture retainers
(abutments) (D6721, D6740, D6751, D6781, D6783 and
D6791).
Not a Benefit for Members under the age of 13.
D6212 Pontic – cast noble metal Not a Benefit.
D6214 Pontic – titanium and titanium Not a Benefit.

alloys
D6240 Pontic – porcelain fused to Not a Benefit.

high noble metal
9705.
D6241 Pontic – porcelain fused to Once in a five-year period; only when the criteria are met
predominantly base metal for a resin partial denture or cast partial denture (D5211,
D6791). Not a Benefit for Members under the age of 13.

noble metal

D6245 Pontic – porcelain/ceramic Once in a five-year period; only when the criteria are met
for a resin partial denture or cast partial denture (D5211,
D6791).
D6250 Pontic – resin with high noble Not a Benefit.

metal
D6251 Pontic – resin with Once in a 5-year period; only when the criteria are met for
predominantly base metal a resin partial denture or cast partial denture (D5211,
D6791).
D6252 Pontic – resin with noble metal Not a Benefit.
D6545 Retainer – cast metal for resin Not a Benefit.

bonded fixed prosthesis
D6548 Retainer – porcelain/ceramic Not a Benefit.

for resin bonded fixed
prosthesis
D6549 Retainer – for resin bonded Not a Benefit.

fixed prosthesis
D6608 Retainer onlay – Not a Benefit.

porcelain/ceramic, two
surfaces
D6609 Retainer onlay – Not a Benefit.

porcelain/ceramic, three or
more surfaces
9705.
D6610 Retainer onlay – cast high Not a Benefit.

noble metal, two surfaces
D6611 Retainer onlay – cast high Not a Benefit.

noble metal, three or more
surfaces
D6612 Retainer onlay – cast Not a Benefit.

predominantly base metal,
two surfaces
D6613 Retainer onlay – cast Not a Benefit.

predominantly base metal,
three or more surfaces
D6614 Retainer onlay – cast noble Not a Benefit.

metal, two surfaces
D6615 Retainer onlay – cast noble Not a Benefit.

metal, three or more surfaces
D6634 Retainer onlay – titanium Not a Benefit.
D6710 Retainer crown – indirect resin Not a Benefit.

based composite
D6720 Retainer crown – resin with Not a Benefit.

high noble metal
D6721 Retainer crown – resin with Once in a five-year period and only when the criteria are
predominantly base metal met for a resin partial denture or cast partial denture
(D5211, D5212, D5213 and D5214).
D6722 Retainer crown – resin with Not a Benefit.

noble metal
D6740 Retainer crown – Once in a five-year period and only when the criteria are
porcelain/ceramic met for a resin partial denture or cast partial denture
(D5211, D5212, D5213 and D5214).
D6750 Retainer crown – porcelain Not a Benefit.

fused to high noble metal
D6751 Retainer crown – porcelain Once in a five-year period and only when the criteria are
fused to predominantly base met for a resin partial denture or cast partial denture
metal (D5211, D5212, D5213 and D5214).

fused to noble metal
9705.

fused to titanium and titanium
alloys
D6781 Retainer crown – 3/4 cast Once in a five-year period and only when the criteria are
(D5211, D5212, D5213 and D5214).
D6782 Retainer crown – 3/4 cast Not a Benefit.

noble metal
D6783 Retainer crown – 3/4 Once in a five-year period and only when the criteria are
porcelain/ceramic met for a resin partial denture or cast partial denture
(D5211, D5212, D5213 and D5214).
Once in a 5 year period and only when the criteria are met
D6784 Retainer crown – 3/4
for a resin partial denture or cast partial denture (D5211,
D5212, D5213 and D5214).
and titanium alloys
D6791 Retainer crown – full cast Once in a five-year period and only when the criteria are
(D5211, D5212, D5213 and D5214).
D6794 Retainer crown – titanium and Not a Benefit.

titanium alloys
D6930 Re-cement or re-bond fixed The original provider is responsible for all re- cementations
partial denture within the first 12 months following the initial placement of
a fixed partial denture. Not a Benefit within 12 months of a
previous re-cementation by the same provider.
D6980 Fixed partial denture repair Not a Benefit within 12 months of initial placement or
necessitated by restorative previous repair, same provider.
material failure
D6999 Unspecified fixed

prosthodontic procedure, by
report
Oral Maxillofacial Prosthetics Procedures (D7000-D7999)
D7111 Extraction, coronal remnants – Not a Benefit for asymptomatic teeth.

primary tooth
D7140 Extraction, erupted tooth or Not a Benefit when removed by the same provider who
exposed root (elevation performed the initial tooth extraction.
and/or forceps removal)
9705.
D7210 Extraction, erupted tooth A Benefit when the removal of any erupted tooth requires
requiring removal of bone the elevation of a mucoperiosteal flap and the removal of
and/or sectioning of tooth, substantial alveolar bone or sectioning of the tooth.
and including elevation of
mucoperiosteal flap if
indicated
D7220 Removal of impacted tooth – A Benefit when the major portion or the entire occlusal
soft tissue surface is covered by mucogingival soft tissue.
D7230 Removal of impacted tooth – A Benefit when the removal of any impacted tooth
partially bony requires the elevation of a mucoperiosteal flap and the
removal of substantial alveolar bone. One of the proximal
heights of contour of the crown shall be covered by bone.
completely bony requires the elevation of a mucoperiosteal flap and the
removal of substantial alveolar bone covering most or all of
the crown.
completely bony, with requires the elevation of a mucoperiosteal flap and the
unusual surgical removal of substantial alveolar bone covering most or all of
complications the crown. Difficulty or complication shall be due to factors
such as nerve dissection or aberrant tooth position.
D7250 Removal of residual tooth A Benefit when the root is completely covered by alveolar
roots (cutting procedure) bone. Not a Benefit to the same provider who performed
the initial tooth extraction.
D7260 Oroantral fistula closure A Benefit for the excision of a fistulous tract between the
maxillary sinus and oral cavity.
D7261 Primary closure of a sinus A Benefit in the absence of a fistulous tract requiring the
perforation repair or immediate closure of the oroantral or oralnasal
communication, subsequent to the removal of a tooth.
D7270 Tooth reimplantation and/or Once per arch regardless of the number of teeth involved
stabilization of accidentally and for permanent anterior teeth only.
evulsed or displaced tooth
D7280 Exposure of an unerupted Not a Benefit:

tooth
• For Members age 19 or older; or
• For third molars.
D7283 Placement of device to Only for Members in active orthodontic treatment.

facilitate eruption of
Not a Benefit:
impacted tooth
• For Members age 19 years or older; and
• For third molars unless the third molar occupies the first
or second molar position.
9705.
D7284 Excisional biopsy of minor

salivary glands
D7285 Incisional biopsy of oral tissue For the removal of the specimen only and once per arch,
– hard (bone, tooth) per date of service regardless of the areas involved.
Not a Benefit with an apicoectomy/ periradicular surgery
(D3410-D3426), an extraction (D7111-D7250) and an
excision of any soft tissues or intraosseous lesions (D7410-
D7461) in the same area or region on the same date of
service.
D7286 Incisional biopsy of oral tissue For the removal of the specimen only and up to a
– soft maximum of three per date of service.
Not a Benefit with an apicoectomy/ periradicular surgery
(D3410-D3426), an extraction (D7111-D7250) and an
excision of any soft tissues or intraosseous
D7287 Exfoliative cytological sample Not a Benefit.

collection
D7288 Brush biopsy – transepithelial Not a Benefit.

sample collection
D7290 Surgical repositioning of teeth For permanent teeth only; once per arch; and only for
Members in active orthodontic treatment.
D7291 Transseptal fiberotomy/supra Once per arch and only for Members in active orthodontic
crestal fiberotomy, by report treatment.
D7310 Alveoloplasty in conjunction A Benefit on the same date of service with two or more
with extractions - four or more extractions (D7140-D7250) in the same quadrant.
teeth or tooth spaces, per
Not a Benefit when only one tooth is extracted in the same
quadrant
quadrant on the same date of service.
D7311 Alveoloplasty in conjunction

with extractions - one to three
teeth or tooth spaces, per
quadrant
D7320 Alveoloplasty not in A Benefit regardless of the number of teeth or tooth

conjunction with extractions - spaces.
four or more teeth or tooth
spaces, per quadrant
D7321 Alveoloplasty not in

conjunction with extractions -
one to three teeth or tooth
spaces, per quadrant
D7340 Vestibuloplasty – ridge Once in a five-year period per arch.

extension (secondary
epithelialization)
9705.
D7350 Vestibuloplasty – ridge Once per arch.

extension (including soft tissue
Not a Benefit:
grafts, muscle reattachment,
revision of soft tissue • On the same date of service with a vestibuloplasty –
attachment and ridge extension (D7340) same arch; and
management of • On the same date of service with extractions (D7111-
hypertrophied and D7250) same arch.
hyperplastic tissue)
D7410 Excision of benign lesion up to

1.25 cm
D7411 Excision of benign lesion

greater than 1.25 cm
D7412 Excision of benign lesion, A Benefit when there is extensive undermining with
complicated advancement or rotational flap closure.
D7413 Excision of malignant lesion up

to 1.25 cm
D7414 Excision of malignant lesion

greater than 1.25 cm
D7415 Excision of malignant lesion, A Benefit when there is extensive undermining with
complicated advancement or rotational flap closure.
D7440 Excision of malignant tumor –

lesion diameter up to 1.25 cm
D7441 Excision of malignant tumor –

lesion diameter greater than
1.25 cm
D7450 Removal of benign

odontogenic cyst or tumor –
D7451 Removal of benign

1.25 cm
D7460 Removal of benign non-

D7461 Removal of benign non-

1.25 cm
9705.
D7465 Destruction of lesion(s) by

physical or chemical method,
by report
D7471 Removal of lateral exostosis Once per quadrant and for the removal of buccal or facial
(maxilla or mandible) exostosis only.
D7472 Removal of torus palatinus Once in the Member’s lifetime.
D7473 Removal of torus mandibularis Once per quadrant.
D7485 Reduction of osseous Once per quadrant.

tuberosity
D7490 Radical resection of maxilla or

mandible
D7509 Marsupialization of
odontogenic cyst
D7510 Incision and drainage of Once per quadrant, same date of service.
abscess – intraoral soft tissue
D7511 Incision and drainage of Once per quadrant, same date of service.
abscess - intraoral soft tissue -
complicated (includes
drainage of multiple fascial
spaces)
D7520 Incision and drainage of

abscess – extraoral soft tissue
D7521 Incision and drainage of

abscess - extraoral soft tissue -
complicated (includes
drainage of multiple fascial
spaces)
D7530 Removal of foreign body from Once per date of service.

mucosa, skin, or
Not a Benefit when associated with the removal of a
subcutaneous alveolar tissue
tumor, cyst (D7440- D7461) or tooth (D7111- D7250).
D7540 Removal of reaction Once per date of service.

producing foreign bodies,
Not a Benefit when associated with the removal of a
musculoskeletal system
tumor, cyst (D7440- D7461) or tooth (D7111- D7250).
D7550 Partial Once per quadrant per date of service and only for the
ostectomy/sequestrectomy removal of loose or sloughed off dead bone caused by
for removal of non-vital bone infection or reduced blood supply.
Not a Benefit within 30 days of an associated extraction
(D7111-D7250).
9705.
D7560 Maxillary sinusotomy for Not a Benefit when a tooth fragment or foreign body is
removal of tooth fragment or retrieved from the tooth socket.
foreign body
D7610 Maxilla – open reduction

(teeth immobilized, if present)
D7620 Maxilla – closed reduction

D7630 Mandible – open reduction

D7640 Mandible – closed reduction

D7650 Malar and/or zygomatic arch

– open reduction

– closed reduction
D7670 Alveolus – closed reduction,

may include stabilization of
teeth
D7671 Alveolus – open reduction,

may include stabilization of
teeth
D7680 Facial bones – complicated For the treatment of simple fractures only.
reduction with fixation and
multiple surgical approaches
D7710 Maxilla – open reduction
D7720 Maxilla – closed reduction
D7730 Mandible – open reduction
D7740 Mandible – closed reduction

– open reduction

– closed reduction
D7770 Alveolus – open reduction

stabilization of teeth
D7771 Alveolus, closed reduction

stabilization of teeth
9705.
D7780 Facial bones – complicated For the treatment of compound fractures only.
reduction with fixation and
multiple approaches
D7810 Open reduction of dislocation
D7820 Closed reduction of

dislocation
D7830 Manipulation under

anesthesia
D7840 Condylectomy
D7850 Surgical discectomy,

with/without implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrostomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7871 Non-arthroscopic lysis and

lavage
D7872 Arthroscopy – diagnosis, with

or without biopsy
D7873 Arthroscopy – lavage and lysis

of adhesions
D7874 Arthroscopy – disc

repositioning and stabilization
D7875 Arthroscopy – synovectomy
D7876 Arthroscopy – discectomy
D7877 Arthroscopy – debridement
D7880 Occlusal orthotic device, by Not a Benefit for the treatment of bruxism.
report
9705.
D7881 Occlusal orthotic device

adjustment
D7899 Unspecified TMD therapy, by Not a Benefit for procedures such as acupuncture,
report acupressure, biofeedback and hypnosis.
D7910 Suture of recent small wounds Not a Benefit for the closure of surgical incisions.
up to 5 cm
D7911 Complicated suture – up to 5 Not a Benefit for the closure of surgical incisions.
cm
D7912 Complicated suture – greater Not a Benefit for the closure of surgical incisions.
than 5 cm
D7920 Skin graft (identify defect Not a Benefit for periodontal grafting.
covered, location and type of
graft)
D7922 Placement of intra-socket

biological dressing to aid in
hemostasis or clot
stabilization, per site
D7939 Indexing for osteotomy using

dynamic robotic assisted or
dynamic navigation
D7940 Osteoplasty – for orthognathic

deformities
D7941 Osteotomy – mandibular rami
D7943 Osteotomy – mandibular rami

with bone graft; includes
obtaining the graft
D7944 Osteotomy – segmented or

subapical
D7945 Osteotomy – body of

mandible
D7946 LeFort I (maxilla – total)
D7947 LeFort I (maxilla – segmented)
D7948 LeFort II or LeFort III

(osteoplasty of facial bones
for midface hypoplasia or
retrusion) – without bone graft
9705.
D7949 LeFort II or LeFort III – with

bone graft
D7950 Osseous, osteoperiosteal, or Not a Benefit for periodontal grafting.

cartilage graft of the
mandible or maxilla –
autogenous or non-
autogenous, by report
D7951 Sinus augmentation with bone Only for Members with authorized implant services.
or bone substitutes via a
lateral open approach
D7952 Sinus augmentation via a Only for Members with authorized implant services.
vertical approach
D7955 Repair of maxillofacial soft Not a Benefit for periodontal grafting.

and/or hard tissue defect

edentulous area – resorbable
barrier, per site

edentulous area – non-
resorbable barrier, per site
D7961 Buccal/labial frenectomy Once per arch per date of service and only when the
(frenulectomy) permanent incisors and cuspids have erupted.
D7962 Lingual frenectomy Once per arch per date of service and only when the
(frenulectomy) permanent incisors and cuspids have erupted.
D7963 Frenuloplasty Once per arch per date of service and only when the
permanent incisors and cuspids have erupted.
Not a Benefit for drug induced hyperplasia or where
removal of tissue requires extensive gingival recontouring.
D7970 Excision of hyperplastic tissue Once per arch per date of service.
– per arch
D7971 Excision of pericoronal gingiva
D7972 Surgical reduction of fibrous Once per quadrant per date of service.
tuberosity
D7979 Non-surgical sialolithotomy
D7980 Surgical sialolithotomy
D7981 Excision of salivary gland, by

report
9705.
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
D7991 Coronoidectomy
D7995 Synthetic graft – mandible or Not a Benefit for periodontal grafting.

facial bones, by report
D7997 Appliance removal (not by Once per arch per date of service and for the removal of
dentist who placed appliances related to surgical procedures only.
appliance), includes removal
Not a Benefit for the removal of orthodontic appliances
of archbar
and space maintainers.
D7999 Unspecified oral surgery

Orthodontics Procedures (D8000-D8999)
D8080 Comprehensive orthodontic Once per Member per phase of treatment; for
treatment of the adolescent handicapping malocclusion, cleft palate and facial
dentition growth management cases; and for permanent dentition
(unless the Member is age 13 or older with primary teeth still
present or has a cleft palate or craniofacial anomaly).
D8210 Removable appliance Once per Member and for Members ages 6 through 12.
therapy
D8220 Fixed appliance therapy Once per Member and for Members ages 6 through 12.
D8660 Pre-orthodontic treatment Once every three months for a maximum of 6 and must be
examination to monitor done prior to comprehensive orthodontic treatment of the
growth and development adolescent dentition (D8080) for the initial treatment phase
for facial growth management cases regardless of how
many dentition phases are required.
D8670 Periodic orthodontic Once per calendar quarter and for permanent dentition
treatment visit - (unless the Member is age 13 or older with primary teeth still
Handicapping malocclusion present or has a cleft palate or craniofacial anomaly).
D8670 Periodic orthodontic Up to a maximum of four quarterly visits. (2 additional

treatment visit cleft palate - quarterly visits shall be authorized when documentation
primary dentition and photographs justify the medical necessity).
D8670 Periodic orthodontic Up to a maximum of five quarterly visits. (3 additional

mixed dentition and photographs justify the medical necessity).
D8670 Periodic orthodontic Up to a maximum of 10 quarterly visits. (5 additional

permanent dentition and photographs justify the medical necessity)
9705.
D8670 Periodic orthodontic Up to a maximum of four quarterly visits. (2 additional

treatment visit facial growth quarterly visits shall be authorized when documentation
management - primary and photographs justify the medical necessity).
dentition
D8670 Periodic orthodontic Up to a maximum of five quarterly visits. (3 additional

management - mixed and photographs justify the medical necessity).
dentition
D8670 Periodic orthodontic Up to a maximum of eight quarterly visits. (four additional

management - permanent and photographs justify the medical necessity).
dentition
D8680 Orthodontic retention Once per arch for each authorized phase of orthodontic
(removal of appliances, treatment and for permanent dentition (unless the
construction and placement Member is age 13 or older with primary teeth still present or
of retainer(s)) has a cleft palate or craniofacial anomaly).
Not a Benefit until the active phase of orthodontic
treatment (D8670) is completed. If fewer than the
authorized number of periodic orthodontic treatment
visit(s) (D8670) are necessary because the active phase of
treatment has been completed early, then this shall be
documented on the claim for orthodontic retention
(D8680).
D8681 Removable orthodontic

retainer adjustment
Once per appliance.
D8696 Repair of orthodontic
appliance – maxillary Not a benefit to the original provider for the replacement
and/or repair of brackets, bands, or arch wires.
Once per appliance.
D8697 Repair of orthodontic
appliance – mandibular Not a benefit to the original provider for the replacement
and/or repair of brackets, bands, or arch wires.
D8698 Re-cement or re-bond fixed Once per provider.

retainer – maxillary
D8699 Re-cement or re-bond fixed Once per provider.

retainer – mandibular
D8701 Repair of fixed retainer,

includes reattachment –
maxillary
D8702 Repair of fixed retainer,

includes reattachment –
mandibular
9705.
D8703 Replacement of lost or broken Once per arch and only within 24 months following the
retainer – maxillary date of service of orthodontic retention (D8680).
D8704 Replacement of lost or broken Once per arch and only within 24 months following the
retainer – mandibular date of service of orthodontic retention (D8680).
D8999 Unspecified orthodontic

Adjunctive General Services Procedures (D9000-D9999)
D9110 Palliative treatment of dental Once per date of service per provider regardless of the
pain – per visit number of teeth and/or areas treated.
Not a Benefit when any other treatment is performed on
the same date of service, except when radiographs/
photographs are needed of the affected area to
diagnose and document the emergency condition.
D9120 Fixed partial denture A Benefit when at least one of the abutment teeth is to be
sectioning retained.
D9210 Local anesthesia not in Once per date of service per provider and only for use in
conjunction with operative or order to perform a differential diagnosis or as a therapeutic
surgical procedures injection to eliminate or control a disease or abnormal
state.
Not a Benefit when any other treatment is performed on
the same date of service, except when radiographs/
photographs are needed of the affected area to
diagnose and document the emergency condition.
D9211 Regional block anesthesia
D9212 Trigeminal division block

anesthesia
D9215 Local anesthesia in

conjunction with operative or
surgical procedures
D9219 Evaluation for moderate

sedation, deep sedation or
general anesthesia
D9222 Deep sedation/general Not a Benefit:

anesthesia - first 15 minutes
• On the same date of service as analgesia, anxiolysis,
inhalation of nitrous oxide (D9230), intravenous
conscious sedation/analgesia (D9241 and D9242) or
non-intravenous conscious sedation (D9248); and
• When all associated procedures on the same date of
service by the same provider are denied.
9705.
D9223 Deep sedation/general

anesthesia - each subsequent
15 minute increment
D9230 Inhalation of nitrous For uncooperative Members under the age of 13, or for
oxide/analgesia, anxiolysis Members age 13 or older when documentation specifically
identifies the physical, behavioral, developmental or
emotional condition that prohibits the Member from
responding to the provider’s attempts to perform
treatment.
Not a Benefit:
• On the same date of service as deep

sedation/general anesthesia (D9223), intravenous
conscious sedation/ analgesia (D9243) or non-
intravenous conscious sedation (D9248); and
D9239 Intravenous moderate Not a Benefit:

(conscious)
sedation/analgesia - first 15 • On the same date of service as deep
minutes sedation/general anesthesia (D9220 and D9221),
analgesia, anxiolysis, inhalation of nitrous oxide (D9230)
or non-intravenous conscious sedation (D9248); and
D9243 Intravenous moderate Not a Benefit:

(conscious)
sedation/analgesia - each • On the same date of service as deep
subsequent 15 minute sedation/general anesthesia (D9223), analgesia,
increment anxiolysis, inhalation of nitrous oxide (D9230) or non-
intravenous conscious sedation (D9248); and
D9248 Non-intravenous conscious Once per date of service; for uncooperative Members
sedation under the age of 13, or for Members age 13 or older when
documentation specifically identifies the physical,
behavioral, developmental or emotional condition that
prohibits the Member from responding to the provider’s
attempts to perform treatment; for oral, patch,
intramuscular or subcutaneous routes of administration.
Not a Benefit:
• On the same date of service as deep

sedation/general anesthesia (D9223), analgesia,
anxiolysis, inhalation of nitrous oxide (D9230) or
intravenous conscious sedation/ analgesia (D9243);
and
9705.
D9310 Consultation – diagnostic

service provided by dentist or
physician other than
requesting dentist or physician
D9311 Consultation with a medical

health professional
D9410 House/extended care facility Once per Member per date of service and only in
call conjunction with procedures that are payable.
D9420 Hospital or ambulatory A Benefit for each hour or fraction thereof as documented
surgical center call on the operative report.
D9430 Office visit for observation Once per date of service per provider.
(during regularly scheduled
Not a Benefit:
hours) - no other services
performed • When procedures other than necessary radiographs
and/or photographs are provided on the same date
of service; and
• For visits to Members residing in a house/ extended
care facility.
D9440 Office visit – after regularly Once per date of service per provider and only with
scheduled hours treatment that is a Benefit.
D9450 Case presentation, Not a Benefit.

subsequent to detailed and
extensive treatment planning
D9610 Therapeutic parenteral drug, Up to a maximum of four injections per date of service.
single administration
Not a Benefit:
• For the administration of an analgesic or sedative

when used in conjunction with deep sedation/general
anesthesia (D9223), analgesia, anxiolysis, inhalation of
nitrous oxide (D9230), intravenous conscious sedation/
analgesia (D9243) or non-intravenous conscious
sedation (D9248); and
D9612 Therapeutic parenteral drugs,

two or more administrations,
different medications
D9910 Application of desensitizing Once in a 12-month period per provider and for
medicament permanent teeth only.
D9930 Treatment of complications Once per date of service per provider; for the treatment of
(post-surgical) – unusual a dry socket or excessive bleeding within 30 days of the
circumstances, by report date of service of an extraction; and for the removal of
bony fragments within 30 days of the date of service of an
extraction.
9705.

Not a Benefit:
• For the removal of bony fragments on the same date

of service as an extraction; and
• For routine post- operative visits.
D9942 Repair and/or reline of Not a Benefit.

occlusal guard
D9943 Occlusal guard adjustment Not a Benefit.
D9944 Occlusal guard – hard Not a Benefit.

appliance, full arch
D9945 Occlusal guard – soft Not a Benefit.

appliance, full arch
D9946 Occlusal guard – hard Not a Benefit.

appliance, partial arch
D9950 Occlusion analysis – mounted Once in a 12-month period; for Members age 13 and older
case only; for diagnosed TMJ dysfunction only; and for
permanent dentition.
Not a Benefit for bruxism only.
D9951 Occlusal adjustment – limited Once in a 12-month period per quadrant per provider; for
Members age 13 and older; and for natural teeth only.
Not a Benefit within 30 days following definitive restorative,
endodontic, removable and fixed prosthodontic treatment
in the same or opposing quadrant.
D9952 Occlusal adjustment – Once in a 12-month period following occlusion analysis-

complete mounted case (D9950); for Members age 13 and older; for
diagnosed TMJ dysfunction only; and for permanent
dentition.
D9995 Teledentistry – synchronous;

real-time encounter
D9996 Teledentistry – asynchronous;

information stored and
forwarded to dentist for
subsequent review
D9997 Dental case management –

patients with special health
care needs
D9999 Unspecified adjunctive

9705.
(Intentionally left blank)
202501A46208
NOTICES AVAILABLE ONLINE
Nondiscrimination and Language Assistance Services
Blue Shield complies with applicable state and federal civil rights laws. We also offer language
assistance services at no additional cost.
View our nondiscrimination notice and language assistance notice: blueshieldca.com/notices.
You can also call for language assistance services: (866) 346-7198 (TTY: 711).
If you are unable to access the website above and would like to receive a copy of the
nondiscrimination notice and language assistance notice, please call Customer Care at
(888) 256-3650 (TTY: 711).
Servicios de asistencia en idiomas y avisos de no discriminación

Blue Shield cumple con las leyes de derechos civiles federales y estatales aplicables. También,
ofrecemos servicios de asistencia en idiomas sin costo adicional.
Vea nuestro aviso de no discriminación y nuestro aviso de asistencia en idiomas en

blueshieldca.com/notices. Para obtener servicios de asistencia en idiomas, también puede llamar al
(866) 346-7198 (TTY: 711).
Si no puede acceder al sitio web que aparece arriba y desea recibir una copia del aviso de no
discriminación y del aviso de asistencia en idiomas, llame a Atención al Cliente al
(888) 256-3650 (TTY: 711).
非歧視通知和語言協助服務
Blue Shield 遵守適用的州及聯邦政府的民權法。同時，我們免費提供語言協助服務。
如需檢視我司的非歧視通知和語言幫助通知，請造訪 blueshieldca.com/notices。您還可致電尋求語言協
助服務：(866) 346-7198 (TTY: 711)。
如果您無法造訪上述網站，且希望收到一份非歧視通知和語言幫助通知的副本，請致電客戶服務部，電
話：(888) 256-3650 (TTY: 711)。
Blue Shield of California is an independent member of the Blue Shield Association A52287GEN-NG_0122

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: Beginning On or After 1/1/2025

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association.

Does this plan provide Minimum Essential Coverage? Yes

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California is an independent member of the Blue Shield Association

Table of contents .......................................................................................................................................2

Medical Provider Network: Exclusive PPO Network

Calendar Year Deductibles (CYD)2

Blue Shield of California is an independent member of the Blue Shield Association

Calendar Year Out-of-Pocket Maximum5

Preventive Health Services7

Other professional services

Pregnancy and maternity care

If admitted to the Hospital, this payment for

Urgent care center services $15/visit 50% 

Ambulance services $75/transport $75/transport

Outpatient Facility services

Inpatient facility services

Bariatric surgery services, designated California

Diagnostic x-ray, imaging, pathology, and laboratory

Rehabilitative and habilitative services

Durable medical equipment (DME)

Home health care services $15/visit Not covered

Home infusion and home injectable therapy services

Skilled Nursing Facility (SNF) services

Hospice program services $0 Not covered

Other services and supplies

Mental Health and Substance Use Disorder Benefits Your payment

Prescription Drug Benefits8,9 Your payment

Retail pharmacy prescription Drugs

15% up to Not covered

Mail service pharmacy prescription Drugs

15% up to Not covered

Pediatric Benefits Your payment

1 Evidence of Coverage (EOC):

2 Calendar Year Deductible (CYD):

3 Using Participating Providers:

4 Using Non-Participating Providers:

“Allowable Amount” is defined in the EOC. In addition:

5 Calendar Year Out-of-Pocket Maximum (OOPM):

6 Separate Member Payments When Multiple Covered Services are Received:

7 Preventive Health Services:

9 Outpatient Prescription Drug Coverage:

10 Pediatric Dental Coverage:

11 Pediatric Vision Coverage:

About this Agreement

Tables and images

This table provides easy access to information

Phone numbers and addresses

Answers to commonly-asked questions

Examples to help you better understand important concepts

This box tells you where to find additional information about a

“You” means the Member

Capitalized words have a special meaning

About this plan

How to contact Customer Service

Contacting Customer Service

If you need information about You should contact

Medical and prescription Drug Benefits, Blue Shield Customer Service:

Acupuncture services American Specialty Health Plans of

American Specialty Health Plans of

Prior authorization of radiological services National Imaging Associates:

Mental Health and Substance Use Mental Health Customer Service:

Pediatric dental Benefits Dental Customer Service:

Blue Shield of California

Pediatric vision Benefits Vision Customer Service:

This Agreement is a contract between you and Blue Shield

Your bill of rights

As a Blue Shield Member, you have the right to: