8/7/2019 Blue Shield of California Essential Plans IFP 1-2011

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Essential packagesIndividual Plans

Medical, dental, and vision coverage – all the essentials in one package.1 

If you want a package that protects you in case of a serious medical event, provides essential benefits for doctor

visits and preventive care, and comes with dental2 and vision3 coverage, one of the EssentialSM PPO packages† 

may be right for you.

Essential plans give you control over the amount you spend on copayments and deductibles – and since they

are only available to individuals and offer essential benefits, you don’t have to pay for services you don’t expect

to use, like maternity care or brand-name drugs.

Three great reasons to choose an Essential package today:

• Threeofficevisitsandgenericprescriptiondrugsrightaway,priortomeetingthemedicaldeductible

• Simpleandaffordablewith100%coverageformostin-networkservicesaftermeetingthemedicaldeductible

• Dentalandvisioncoverage

See for yourself all the great benefits of Essential plans

Essential 1750 Essential 3000 Essential 4500

Office visits $404 each for first 3 visits

Preventive care exam $0

Mammogram and GYN

screening

$0

Inpatient hospitalization $0afterdeductible

Outpatient surgery $0afterdeductible

Lab and X-ray $0afterdeductible

Emergency room $100(waivedifadmitted)5

Maternity Not covered

Generic Rx $10

Brand formulary Rx6 Not covered

Annual deductible $1,75 0permem ber $ 3,00 0permem ber $ 4,50 0permem ber

Annual out-of-pocket

maximum (includes

deductible)

$1,75 0permem ber $ 3,00 0permem ber $ 4,50 0permem ber

Amountsshownrepresentthemember’sfinancialresponsibilitywhenusingBlueShieldnetworkproviders.Thisdocumentisasummaryonly.Foradetailed description of plan benefits and exclusions, request a copy of the Policy by calling Member Services at (800) 431-2809.

Essential 1750

Essential 3000

Essential 4500

8/7/2019 Blue Shield of California Essential Plans IFP 1-2011

http://slidepdf.com/reader/full/blue-shield-of-california-essential-plans-ifp-1-2011 2/2

   A  n

   I  n   d  e  p  e  n   d  e  n   t   L   i  c  e  n  s  e  e

  o   f   t   h  e

   B   l  u  e

   S   h   i  e   l   d

   A  s  s  o  c   i  a   t   i  o  n

    A    3    6    8    1    0    (    1    /    1    1    )

Advantages of Blue Shield Individual and Family plans

• Affordable–we’venegotiatedwithprovidersfor  

lower fees, so you’ll pay less for covered medical

services. A lot less.

• Withmorethan60,000doctors,BlueShieldhassome  

of the largest PPO provider networks in California. I f

you already have a doctor, chances are your doctor

is in one of our networks.

• Lotsofextrassuchasaround-the-clockaccesstoa

registered nurse, wellness programs and discounts,

and out-of-state coverage at no additional cost.

• 20%visiondiscountsforeyeexams,framesandlenses,

and other products.7

Understanding your plan

Tomakehealthcoverageeasierforyou,hereisasimple

description of how these plans work:

• Mostmedicalbenefitsaresubjecttoyourannual

deductible, but some benefits – like the first three

office visits and generic prescription drugs – you

receive right away for a copayment.

• Formostothermedicalservices,you’llpaythe

reduced fee we negotiated with your provider until

you’vereachedyourannualdeductible/out-of-pocket

maximum.Afterthat,we’llpay100%ofyourcostsfor

most covered medical services.8

t EssentialpackagesareunderwrittenbyBlueShieldofCaliforniaLife&HealthInsuranceCompany.Essential1750ispendingregulatoryapproval.

1 TheEssentialpackageconsistsofamedicalplan,adentalplan,andavisionplanofferedtogetheratapackagerate.TheEssentialDentalPPOPlanwill

appear as a separate rate on your bill, however, it is part of the Essential package rate which must be paid in its entirety for the Essential coverage to

remaineffective.TheEssentialDentalPPOPlanmaybereplacedwithaseparateBlueShielddentalplan.

2 TheEssentialSMDentalPPOPlanbenefitincludescoverageforpreventiveexams,teethcleaning,diagnostic,andminorrestorativeservices.Dental

servicesareprovidedthroughacontracteddentalplanadministrator.Combineddentalbenefitsarelimitedto$500percalendaryear.Athree-month

waitingperiodfollowingtheeffectivedateofcoverageisrequiredforminorrestorativeservices.Minorrestorativeservicesaresubjecttoaseparate$50

deductible.

3 WiththeEssentialSM Vision PPO Plan benefit you receive an annual vision exam in California for $5.

4 After3visitspermemberperyear,subsequentvisitsare$0afterdeductible.

5 Emergencyroomphysicianis$0afterdeductible.

6 Brand-namedrugsarenotcovered,withtheexceptionofcovereddrugsandsuppliesfordiabetes.Brandandgenericdiabetesmedications/supplies

arecovered,andmaybesubjecttoPriorAuthorizationformedicalnecessity.

7 ThenetworkofpractitionersandfacilitiesintheDiscountVisionProgramaremanagedbyacontractedvisionplanadministrator(includingany

screeningandcredentialingofprovider).BlueShielddoesnotreviewtheservicesprovidedbydiscountprogramprovidersformedicalnecessityor

efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees,

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

benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services

received from the discount program may use the Blue Shield grievance process described in the Grievance Process section of the Policy. Blue Shield

reserves the right to terminate this program at any time without notice.

8 Member payments for emergency room services and prescriptions do not count toward the medical deductible or out-of-pocket maximum, and

continue to be charged once the out-of-pocket maximum has been met. See the medical Policy for more details.

Get the essential coverageyou need with an

Essential package today!