Preventive Care

BLUE SHIELD SIGNATURE HMO

This is a general summary of Blue Shield Signature health maintenance organization (HMO) benefits. A more complete description of benefits and coverage, including limitations and exclusions, is contained in the plan documents and evidence of coverage document (EOC). If there are any discrepancies between the information contained in this summary and the provisions of the plan documents, the provisions of the plan documents will prevail.

Blue Shield Signature HMO is a plan that offers Level II preferred provider organization (PPO) access. The HMO provision requires that you select a primary care physician (PCP) from one of the Blue Shield participating physician groups. Under Level I (the HMO), you receive all of your care from within your PCP’s network of participating physicians, hospitals, and other health care providers. Under Level II (the PPO access), you are allowed consultations with a doctor outside of your participating physician group, but within Blue Shield’s PPO network, without a referral from your PCP.

BLUE SHIELD ACCESS+ HMO

This is a general summary of Blue Shield Access+ HMO benefits. A more complete description of benefits and coverage, including limitations and exclusions, is contained in the plan documents and evidence of coverage document (EOC). If there are any discrepancies between the information contained in this summary and the provisions of the plan documents, the provisions of the plan documents will prevail.

Blue Shield Access+ HMO is a health maintenance organization (HMO) plan that offers members the ability to self-refer to a specialist within their medical group for certain services. The Access+ HMO requires that you select a primary care physician (PCP) from one of the Blue Shield participating physician groups.

With Blue Shield’s Access+ HMO, you receive all of your care from within your PCP’s network of participating physicians, hospitals, and other health care providers, unless you are experiencing a life-threatening emergency.

BLUE SHIELD PPO & BLUE SHIELD NEEDLES PPO

Both the Blue Shield PPO and Blue Shield Needles PPO are preferred provider organizations (PPO). A PPO is a medical plan that offers you a choice between an in-network group of providers who offer their services at discounted rates and out-of-network providers without discounted rates. Under a PPO plan, you may choose the level of benefits you receive based on the providers you use when you receive care.

With Blue Shield PPO and Blue Shield Needles PPO, you may obtain care from an in-network or out-of-network provider. It’s your choice. However, when you receive your medical care from in-network, or PPO providers, the plan pays 80% of most covered expenses. Some covered expenses are paid only after you have paid the deductible. If you use out-of-network providers, benefits will be 70% of usual, customary, and reasonable (Allowable Amount) services for the area. You will pay 30% of the Allowable Amount and all charges above the Allowable Amount. With out-of-network providers, the plan cannot guarantee that your chosen provider will charge fees common to the area, so your out-of-pocket costs could exceed 30%. You pay a calendar year deductible before the plan pays for certain services obtained from an in-network (“participating”) or out-of-network (“nonparticipating”) provider as follows:

• Shield PPO–$250 per member,$500 per family

• Shield Needles PPO (out-of-network)–$250 per member,$500 per two-party,$750 per family

ADDITIONAL BLUE SHIELD BENEFITS

Urgent Care

Accessing Urgent Care is simple as a Blue Shield member. As a member of the Shield Signature or PPO plan, you can use any Blue Shield HMO or PPO network urgent care. If you are an Access+ member, you must use an urgent care that is affiliated with your medical group when in the medical group’s service area.

Emergency Care

Members who reasonably believe that they have an emergency medical condition which requires an emergency response are encouraged to appropriately use the “911” emergency response system where available. Members should go to the closest plan hospital for emergency services whenever possible.

If you obtain emergency services, you should notify your PCP within 24 hours after care is received unless it was not reasonably possible to communicate with the PCP within this time limit. In such case, notice should be given as soon as possible.

An emergency means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

1. Placing the member’s health in serious jeopardy;

2. Serious impairment to bodily functions;

3. Serious dysfunction of any bodily organ or part.

If you receive non-authorized services in a situation that Blue Shield determines was not a situation in which a reasonable person would believe that an emergency condition existed, you will be responsible for the costs of those services.

Tele-Medicine – $0 Co-pay Access to care – anytime, anywhere

Telephone and video appointments are available 24/7 for non-emergency conditions such as allergies, colds, coughs and upper respiratory infections. Call (800) 835-2362 or register online at www.teladoc.com. You will need to provide your medical history prior to requesting a consultation. Dependents under 18 can be registered under your account; adult dependents must register for their own account.

Short-Term Out-of-Area Care

Outside of California: The Blue Shield Signature HMO provides coverage for you and your family for your urgent care service needs when you or your family are temporarily traveling outside of California. You can receive urgent care services from any provider; however, using the BlueCard® Program, described below, can be more cost-effective and eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement.

NOTE: Authorization by Blue Shield is required for care that involves a surgical or other procedure or inpatient stay.

Out-of-area follow-up care is covered and services may be received through the BlueCard Program participating provider network or from any provider. However, authorization by Blue Shield is required for more than two out-of-area follow-up care outpatient visits. Blue Shield may direct the patient to receive the additional follow-up services from the PCP.

Within California: If you need urgent medical care, but are outside of your PCP service area, if possible, you should call the Blue Shield member services team. You may also locate a plan provider by visiting our web site at www.blueshieldca.com/fad. However, you are not required to use a Blue Shield of California plan provider to receive urgent care services. You may use any provider.

ELIGIBILITY & ENROLLMENT

NOTE: Authorization by Blue Shield is required for care that involves a surgical or other procedure or inpatient stay.

Follow-up care is also covered through a Blue Shield of California plan provider and may also be received from any provider. However, when outside your PCP service area, authorization by BlueShield HMO is required for more than two out-of-area follow-up care outpatient visits. Blue Shield HMO may direct the patient to receive the additional follow-up services from the PCP. If services are not received from a Blue Shield of California plan provider, you may be required to pay the provider for the entire cost of the service and submit a claim to Blue Shield HMO. Claims for urgent care services obtained outside of your PCP service area within California will be reviewed retrospectively for coverage. When you receive covered urgent care services outside your PCP service area within California, the amount you pay, if not subject to a flat dollar copay, is calculated based upon Blue Shield’s allowed charges.

BlueCard Program: Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Plans and their licensed controlled affiliates (licensees) referred to generally as inter-plan programs. Whenever you obtain healthcare services outside of California, the claims for these services may be processed through one of these inter-plan programs.

When you access covered services outside of California, you may obtain care from healthcare providers that have a contractual agreement (i.e., are “participating providers”) with the local BlueCross and/or Blue Shield licensee in that other geographic area (host plan). In some instances, you may obtain care from non-participating healthcare providers.

Please obtain full details on the Blue Card Program from the current Blue Shield EOC or by calling the Blue Shield member services team at (855) 599-2657.

Long-Term Out-of-Area Care

Students, long-term travelers, and families living apart can rely on access to routine care, urgent care, and emergency services in select states with the Away From Home Care® Program. Note that a 30- day notification is required prior to participation in the Away From Home Care® Program. You may call (800) 622-9402 to coordinate use of this benefit or for more information about availability and state- specific coverage.

Medical Transition of Care Benefit

As a new member, you are entitled to a medical review that may allow you to continue your current treatment plan due to a specific diagnosis for a specified time frame with your prior provider. Some examples of circumstances for you or a family member are:

• You are in the second or third trimester of pregnancy or a high-risk pregnancy and are currently established with an obstetrician.

• You are scheduled for surgery within 3 weeks after your effective date of coverage.

• You have documented follow-up care for surgery that was completed within 6 weeks prior to your effective date of coverage.

• You have complications resulting from surgery performed within the month prior to your effective date of coverage.

• You are presently undergoing a course of chemotherapy or radiation therapy.

• You are approved for or on a waiting list for a transplant.

• You have an acute or serious chronic condition.

• You are currently receiving outpatient mental health treatment or you arec urrently in a chemical dependency treatment program.

ELIGIBILITY & ENROLLMENT

If you have a transition of care issue, please contact the Blue Shield member services team at (855) 599-2657 and ask for assistance with transition of care. Blue Shield will assign you a case manager to guide and assist you with your specific transition of care needs.

How to Enroll

New employees must enroll within 60 days of hire into an eligible position. Proof of dependent status is required for each dependent you enroll on the plan. Please refer to the Eligibility and Enrollment section of this guide for specific details.

What’s Covered

While covered under Blue Shield, you can take advantage of comprehensive medical benefits. Please refer to the Medical Plans Comparison Chart of this guide for a summary of covered expenses. Remember, this guide only provides a summary of the benefits available through Blue Shield. The Blue Shield contract and EOC determines the exact terms, conditions, and applicable coverage exclusions.

How to Get in Touch with Blue Shield

Call Blue Shield member services team at (855) 599-2657 any time between 7:00 a.m. and 7:00 p.m. Monday – Friday or visit Blue Shield’s web site at www.blueshieldca.com for more information.

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EYEMED VISION

The County of San Bernardino has contracted with EyeMed Vision Care to provide vision care benefits. Detailed plan information, including the EyeMed Vision Care master policy, can be obtained online at hr.sbcounty.gov/employee-benefits/medical-dental-vision-plans/eyemed-vision-care

The County of San Bernardino participates in a comprehensive plan that offers you every 12 months:

• No eye exam copayments

• Large nation-wide network of vision care providers

• Freedom to see any provider you choose

• Savings on retinal imaging

• 40% off on additional pairs of prescription eyewear

• 15% off Lasik retail

• Customer service representatives available 7 days a week and evenings

Register at eyemed.com to access benefit information, locator a provider, check claim status and print ID cards. You can also use your benefits with online retailers.

EyeMed members can also find great discounts and deals for a variety of vison related products and services on the Special offers page of the member portal at eyemed.com.

A more complete description of benefits and coverage, including limitations and exclusions, is contained in the EyeMed Master Policy.

If you are enrolled in more than one EyeMed Vision Care plan, you will receive the benefits of the plan that is presented at the time of service; the benefits do not coordinate.

How to Get in Touch with EyeMed Vision Care

For further information, please contact the EyeMed Vision Care customer care team at (877) 406-4146. Service representatives are available Monday–Saturday from 4:30 a.m. to 8:00 p.m. (PST) and Sunday from 8:00 a.m. to 5:00 p.m. (PST).

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