Blue Shield PPO Blue Shield HMO Blue Shield Short Term Blue Shield Senior
Applications Provider Finder Members  

Blue Shield

Blue Shield Access Plus HMO

Oleg Skurskiy An Authorized Agent of Blue Shield of California Call : (818) 654-4548
 
Get A Quote Apply now
 

Health & Dental Plans
Access+HMO


These plans are often selected by people who go to the doctor more frequently. Choose your own Personal Physician and get easy access to specialists, plus a wide range of benefits.

Plan Features

  • Preventive, routine and catastrophic care
  • Access+Specialist lets you visit a participating specialist within your Personal Physician's medical group without a referral for just a $30 copayment.
  • Preventive care services at no charge
  • Prescription generic drugs are only $10 per prescription at participating pharmacies
  • Choose a Personal Physician from an extensive network. Office visits with your Personal Physician are covered with a $20/visit copayment.
  • Built-in dental benefits for no extra monthly dues through Access+Dentist
  • Virtually no claim forms
  • No lifetime maximum on plan benefits
  • Injectable contraceptives


    Get complete details for this plan Go Here

  • Download Application Click here

Access+ HMO

DEDUCTIBLE*

$2,000 ($4,000 Family)
 

CALENDAR-YEAR OUT-OF-POCKET MAXIMUM
The calendar year copayment maximum includes the plan deductible
(The copayments indicated with ∞do not apply towards the out-of-pocket maximum amount.

$3,000 ($6,000 Family)

LIFETIME BENEFIT MAXIMUM

No Limit

* Benefits for covered brand-name drugs are subject to a separate $200 brand-name drug deductible per person for formulary and non-formulary.

COVERED SERVICES1

MEMBER COPAYMENTS

PROFESSIONAL SERVICES

– Personal Physician office visits

$20/visit

– Injectable medications, lab and X-ray

$20

– Access+ Specialist(Self-referred physician office visits or other consultations only)2

  

$35/visit ∞

– Physician home visits

$35/visit

PREVENTIVE CARE

– Scheduled Routine Physical Exams, annual Gynecological Exam, immunizations, vision, hearing and routine lab screenings

$20

OUTPATIENT SERVICES

Non-Emergency

– Outpatient Surgery (in a hospital)

$250/visit

– Outpatient Services and Supplies (in a hospital; includes radiation and intravenous chemotherapy)

$35/visit

HOSPITALIZATION SERVICES

– Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists
(covered inpatient hospital, skilled nursing facility and subacute care physician services)

$20/visit

– Inpatient semiprivate room and board, intensive care units, subacute care, special treatment rooms, services and supplies

$250/admit

EMERGENCY HEALTH COVERAGE

– Emergency room services ($75 copayment waived if the member is admitted directly to the hospital as an inpatient)

$75/visit

– Inpatient hospital services and supplies

$250/admit

AMBULANCE SERVICES (Surface or Air)

$50/trip

PRESCRIPTION DRUG COVERAGE3
( Brand-name drugs subject to a $200 brand-name drug deductible. Prescription coverage differs for Home Self-Injectables.
Please review the EOC before you purchase the plan.)

At Participating Pharmacies
(up to a 30-day supply)

Mail Service Prescriptions
(up to a 60-day supply)

– Generic drugs

$10/prescription ∞

$20/prescription ∞

– Formulary brand-name drugs4

$35/prescription ∞

$70/prescription ∞

DURABLE MEDICAL EQUIPMENT5

50% ∞

MENTAL HEALTH SERVICES8

– Inpatient Hospital Facility Services

$250/admit

– Inpatient Physician Services

$20/visit

– Outpatient visits for severe mental health conditions2

$20/visit ($35/visit ∞if provider is MHSA

Access+ Specialistprovider)

– Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with
chemical dependency visits)2

  

$25/visit∞ ($35/visit∞ if provider is MHSA

Access+ Specialistprovider)

COVERED SERVICES1

MEMBER COPAYMENTS

CHEMICAL DEPENDENCY SERVICES (Substance Abuse)8

– Inpatient hospital facility services for medical acute detoxification

$250/admit

– Outpatient visits(up to 20 visits per calendar year combined with non-severe mental health visits)2

  

$25/visit∞ ($35/visit∞if provider is MHSA

Access+ Specialistprovider)

HOME HEALTH SERVICES (up to 100 visits per calendar year)

– Home Health Agency visits (up to 4 visits per day, 2 hours per visit)

$20/visit

OTHER

Pregnancy and Maternity Care6

– Outpatient prenatal and postnatal physician office visits

$20/visit

– Delivery and all necessary inpatient hospital services

$250/admit

Family Planning

– Counseling

$20/visit

– Tubal ligation,7elective abortion

$100/occurence

– Vasectomy

$75/occurence

Rehabilitation Services – physical, occupational and respiratory therapy

– Received in a physician’s office visit or in hospital outpatient department

$20/visit

– In Inpatient rehabilitation unit of hospital

$250/admit

Urgent Care(outside your Plan Service Area)9

$50/visit

Dental Services(for details please see the Dental Highlights Matrix in the Dental, Life Insurance product sheet)

– Access+ Dentist

Embedded within this Plan
Active Start Plan 35 PPO - No Medical Deductible   Shield Spectrum PPO 5000   Access®+ Value HMO
Active Start Plan 25 PPO - No Medical Deductible   Shield Spectrum PPO 2000   Access®+ HMO
Balance Plan PPO 1000 - no Maternity   Shield Spectrum PPO 1500    
Balance Plan PPO 1700 - no Maternity   Shield Spectrum PPO 750   Blue Shield Senior
Balance Plan PPO 2500 - no Maternity   Shield Spectrum PPO 500    
Essential Plan PPO 1750 Dental & Vision Included   Blue Shield Short Term
Essential Plan PPO 3000 Dental & Vision Included HSA Savings Plan 2400 / 4800  
Essential Plan PPO 4500 Dental & Vision Included HSA Savings Plan 4000 / 8000  

 

 
 

Please Note: Benefits are subject to modification for subsequently enacted state or federal legislation. 1 Access+ HMO benefits are provided only for services that are medically necessary, as determined by the Personal Physician or Access+ HMO except in an emergency or as otherwise specified, and must be received while the patient is a current member.

2 To use the Access+ Specialist option, for other than mental health or substance abuse services, your Personal Physician must belong to a medical group or IPA that has decided to become an Access+ Provider Group. Access+ Specialist visits for mental health services for other than Severe Mental Illnesses or Serious Emotional Disturbances of a Child, and for Substance Abuse Care will accrue towards the 20-visit-per-calendar-year maximum. In addition, all Access+ Specialist visits require a copayment per visit. Mental health and substance abuse Access+ Specialist visits are accessed through the MHSA utilizing MHSA participating providers.

3 Only medically necessary outpatient formulary drugs are covered unless prior authorization is obtained from Blue Shield Pharmacy Services. Non-formulary drugs may be covered only if prior authorization is obtained from Blue Shield Pharmacy Services. After all necessary documentation is available from your Physician, prior authorization approval or denial will be provided to your Physician within two working days of the request. Member is then responsible for the brand prescription copayment.

4 If a member or the physician requests a brand-name drug when an equivalent generic drug is available, the member pays the generic copayment plus the cost difference between the brand and generic drug at retail or mail order pharmacies.

5 All covered orthotic equipment and services have a benefit maximum of $2,000 per member per calendar year, except those services covered under the Diabetes Care benefit.

6 Except for the treatment of involuntary complications of pregnancy, pregnancy/maternity benefits for a pregnancy that qualifies as a Waivered Condition are not available during the six-month period beginning as of the effective date of coverage.

7 The tubal ligation copayment does not apply when the procedure is performed in conjunction with delivery or abdominal surgery.

8 Blue Shield of California has contracted with a specialized health care service plan to act as the plan’s mental health services administrator (MHSA) and to provide mental health and substance abuse services, other than inpatient services for medical acute detoxification, through a separate network of MHSA participating providers. Inpatient services for medical acute detoxification are accessed through Blue Shield utilizing HMO network providers. For all other mental health and substance abuse services, members should access MHSA participating providers.

9 Authorization by Blue Shield is required for more than two out-of-area follow-up outpatient visits or for out-of-area follow-up care that involves a surgical or other procedure or inpatient stay. After all necessary documentation is available from your Physician, prior authorization approval or denial will be provided to your Physician within two working days of the request.

 

 


 
   
Site Map
Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389
blueshieldofcalifornia Blue Cross Blue Cross Tonik Unicare