| The out-of-pocket/copayment maximums
include the plan deductible.
e The deductible only applies to
facility charges for inpatient hospital
services, outpatient hospital surgery
services, skilled nursing facility
services, hospice program services
and ambulatory surgery center services.
p The initial flat dollar emergency
room copayment is waived if you
are admitted directly to the hospital
as an inpatient.
? Copayments apply for covered preventive
care and diagnostic services. Certain
other dental services are covered
at 20% based on the attending dentist's
billed charges. Orthodontics are
With an HMO plan, members must live
or work within the Blue Shield HMO
service area and have a designated
Personal Physician to enroll and
maintain enrollment. The Blue Shield
HMO service area is identified in
the HMO Physician and Hospital Directory.
Each eligible family member may
select a different Personal Physician,
as long as each provider is located
adequately close to the member's
home or work address to ensure access
to care (as determined by Blue Shield).
This information is intended as
a brief comparison of some of the
benefits of the various Blue Shield
plans and shows copay/coinsurance
amounts you will pay for services
received from preferred providers
only. You should review the Combined
Summary of Benefits or the Evidence
of Coverage/Certificate of Insurance
and Plan Contract/Policy for a more
complete description of the benefits,
terms and conditions and limitations
of the health plans.
Note: The federal Health Insurance
Portability and Accountability Act
(HIPAA) makes it easier for people
with pre-existing conditions who
are covered under existing group
health plans to maintain coverage
of pre-existing conditions when
they change jobs or are unemployed
for brief periods of time. If you
meet all the specified conditions,
you may be eligible for a guaranteed
issue plan in accordance with HIPAA.
For more information, contact your
agent or call Blue Shield at (888)
† Underwritten by Blue Shield
of California Life & Health
Insurance Company (Blue Shield Life).