Platinum_90_PPO_1-16

Platinum 90 PPO

 

Uniform Health Plan Benefits and Coverage Matrix

 

Blue Shield of California

Effective January 1, 2016

 

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

 

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This health plan uses the Exclusive PPO Provider Network.

 

 

Participating Providers1

Non-Participating Providers1

Calendar Year Medical Deductible1

$0

$0

Calendar Year Out-of-Pocket Maximum2

(Copayments or coinsurance for covered services from participating providers accrues to both the participating and non- participating provider calendar year out-of-pocket maximum

amounts.)

$4,000 per individual /

$8,000 per family

$7,000 per individual /

$14,000 per family

Lifetime Benefit Maximum

None

 

Covered Services

Member Copayments

 

Participating Providers1

Non-Participating Providers1

PROFESSIONAL SERVICES

 

 

Professional Benefits

 

 

Primary care physician office visit

$20

50%

Other practitioner office visit

$20

50%

Specialist physician office visit

$40

50%

Allergy Testing and Treatment Benefits

Primary care physician office visits (includes visits for allergy serum injections)

$20

50%

Specialist physician office visits (includes visits for allergy serum injections)

$40

50%

Allergy serum purchased separately for treatment

10%

50%

Preventive Health Benefits16

Preventive health services

(as required by applicable Federal and California law)

$0

Not covered

OUTPATIENT SERVICES

 

 

Hospital Benefits (Facility Services)

 

 

Outpatient surgery performed at a free- standing ambulatory surgery center

10%

50%5

The maximum allowed amount for non-participating providers is $300 per day.

Members are responsible for 50% of this $300 per

day, plus all charges in excess of $300

Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center

10%

50%3

The maximum allowed amount for non-participating providers is $500 per day.

Members are responsible for 50% of this $500 per day, plus all charges in excess of $500

Outpatient visit

10%

50%3

The maximum allowed amount for non-participating providers is $500 per day.

Members are responsible for 50% of this $500 per

day, plus all charges in excess of $500

Outpatient services for treatment of illness or injury and necessary supplies

(except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")

10%

50%3

The maximum allowed amount for non-participating providers is $500 per day.

Members are responsible for 50% of this $500 per

day, plus all charges in excess of $500

 

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Covered Services

Member Copayments

 

Participating Providers1

Non-Participating Providers1

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital18

(prior authorization is required)

10%

50%3

The maximum allowed amount for non-participating providers is $500 per day.

Members are responsible for 50% of this $500 per

day, plus all charges in excess of $500

Outpatient diagnostic x-ray and imaging performed in a hospital18

$40

50%3

The maximum allowed amount for non-participating providers is $500 per day.

Members are responsible for 50% of this $500 per

day, plus all charges in excess of $500

Outpatient diagnostic laboratory and pathology performed in a hospital18

$20

50%3

The maximum allowed amount for non-participating providers is $500 per day.

Members are responsible for 50% of this $500 per day, plus all charges in excess of $500

Bariatric surgery6

(prior authorization is required; medically necessary surgery

for weight loss, for morbid obesity only)6

10%

Not Covered

 

HOSPITALIZATION SERVICES

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Hospital Benefits (Facility Services)

 

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Inpatient physician fee

10%

50%

Inpatient non-emergency facility fee

(semi-private room and board, and medically necessary services and supplies, including sub-acute care)

10%

50%3

The maximum allowed amount for non-participating providers is $2000 per day.

Members are responsible for 50% of this $2000 per

day, plus all charges in excess of $2000

Bariatric surgery6

(prior authorization is required; medically necessary surgery for weight loss is for morbid obesity only)

10%

Not covered

 

Inpatient Skilled Nursing Benefits19,4

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(combined maximum of up to 100 days per benefit period; prior authorization is required; semi -private accommodations)

Services by a free-standing skilled nursing facility

10%

10%

Skilled nursing unit of a hospital

10%

50%3

The maximum allowed amount for non-participating providers is $2000 per day.

Members are responsible for 50% of

this $2000 per day, plus all charges in excess of $2000

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EMERGENCY HEALTH COVERAGE

Emergency room visit not resulting in admission - facility fee

(copayment does not apply if the member is directly

admitted to the hospital for inpatient services)

$150

$150

Emergency room visit resulting in admission - facility fee

(when the member is admitted directly from the ER)

10%

10%

Emergency room visit not resulting in admission - physician fee(copayment does not apply if the member is directly admitted to the hospital for inpatient

services)

10%

10%

Emergency room visit resulting in admission - physician fee

10%

10%

Urgent care

$40

50%

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AMBULANCE SERVICES

Emergency or authorized transport

(ground or air)

$150

$150

PRESCRIPTION DRUG (PHARMACY)COVERAGE7,8,9,11,17,20

Participating Pharmacy

Non-Participating Pharmacy

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Retail Pharmacies (up to a 30-day supply)

Contraceptive drugs and devices8

$0

Not covered

Tier 1 Drugs

$5 per prescription

Not covered

Tier 2 Drugs

$15 per prescription

Not covered

Tier 3 Drugs

$25 per prescription

Not covered

Tier 4 Drugs (excluding Specialty Drugs)

10% up to $250 maximum per prescription

Not covered

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Mail Service Pharmacies (up to a 90-day supply)

Contraceptive drugs and devices8

$0

Not covered

Tier 1 Drugs

$15 per prescription

Not covered

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Tier 2 Drugs

$45 per prescription

Not covered

 

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Covered Services

Member Copayments

 

Participating Providers1

Non-Participating Providers1

Tier 3 Drugs

$75 per prescription

Not covered

Tier 4 Drugs (excluding Specialty Drugs)

10% up to $750 maximum per prescription

Not covered

 

Network Specialty Pharmacies11,17,20 (up to a 30-day supply)

Tier 4 Drugs

10% up to $250 maximum per prescription

Not covered

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Oral anti-cancer medications

10% up to a maximum of $200 per prescription

Not covered

 

Participating Providers1

Non-Participating Providers1

PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices

(separate office visit copayment may apply)

10%

50%

Orthotic equipment and devices

(separate office visit copayment may apply)

10%

50%

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DURABLE MEDICAL EQUIPMENT

 

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Breast pump

$0

Not covered

Other durable medical equipment

10%

50%

 

MENTAL HEALTH AND BEHAVIORAL HEALTH SERVICES10

 

 

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Inpatient hospital services

(prior authorization required)

10%

50%3

The maximum allowed amount for non-participating providers is $2000 per day.

Members are responsible for 50% of this $2000per

day, plus all charges in excess of $2000

Residential care(prior authorization required)

10%

50%3

The maximum allowed amount for non-participating providers is $2000 per day.

Members are responsible for 50% of this $2000 per day, plus all charges in excess of $2000

Inpatient professional (physician) services(prior authorization required)

10%

50%

Routine outpatient mental health and

behavioral health services

(includes professional/physician visits; some services may require prior authorization and facility charges)

$20

50%

Non-routine outpatient mental health and behavioral health services(includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, partial hospitalization programs, transcranial magnetic stimulation, post discharge ancillary care and psychological testing. For partial hospitalization programs, a higher copayment and facility charges may

apply per episode of care. Some services may require prior

authorization and facility charges)

10%

50%

 

SUBSTANCE USE DISORDER SERVICES10

Inpatient hospital services(prior authorization required)

10%

50%3

The maximum allowed amount for non-participating providers is $2000 per day.

Members are responsible for 50% of this $2000per day, plus all charges in

excess of $2000

Residential care(prior authorization required)

10%

50%3

The maximum allowed amount for non-participating providers is $2000 per day.

Members are responsible for 50% of this $2000 per day, plus all charges in excess of $2000

Inpatient professional (physician) services

(prior authorization required)

10%

50%

Routine outpatient substance use disorder services

(includes professional/physician visits; some services may require prior authorization and facility charges)

$20

50%

Non-routine outpatient substance use disorder services(includes intensive outpatient programs, partial hospitalization programs, office-based opioid treatment, and post discharge ancillary care. For partial hospitalization programs, a higher copayment and facility charges may apply per episode of care. Some services may require prior

authorization and facility charges)

10%

50%

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HOME HEALTH SERVICES

Home health care agency visit19

(up to 100 prior authorized visits per calendar year)

10%

Not covered

 

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Covered Services

Member Copayments

 

Participating Providers1

Non-Participating Providers1

Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a home infusion agency19

(up to 100 prior authorized visits per calendar year)

10%

Not covered

 

HOSPICE PROGRAM BENEFITS

Routine home care

No Charge

Not Covered

Inpatient respite care

No Charge

Not Covered

24-hour continuous home care

No Charge

Not Covered

Short-term inpatient care for pain and symptom management

No Charge

Not Covered

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CHIROPRACTIC BENEFITS

Chiropractic services

Not covered

Not covered

ACUPUNCTURE BENEFITS

Acupuncture services(benefits provided are for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain only)

$20

50%

REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy)

Office location

$20

50%

SPEECH THERAPY BENEFITS

Office location

$20

50%

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PREGNANCY AND MATERNITY CARE BENEFITS

Prenatal and preconception physician office visit

(for inpatient hospital services, see "Hospitalization Services")

$0

50%

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Delivery and all inpatient physician services

10%

50%

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Postnatal physician office visit

(for inpatient hospital services, see "Hospitalization Services")

$20

50%

Abortion services

(an additional facility copayment may apply when services

are rendered in a hospital or outpatient surgery center)

10%

50%

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FAMILY PLANNING BENEFITS

Counseling and consulting

(includes insertion of IUD, as well as injectable and

implantable contraceptives for women)

$0

Not covered

Tubal ligation

$0

Not covered

Vasectomy

(an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

10%

Not covered

Infertility services

Not covered

Not covered

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DIABETES CARE BENEFITS

Devices, equipment, and non-testing supplies

(for testing supplies see Outpatient Prescription Drug

Benefits)

10%

50%

Diabetes self-management training in an office setting

$20

50%

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Within US: BlueCard Program

See Applicable Benefit

See Applicable Benefit

Outside of US: BlueCard Worldwide

See Applicable Benefit

See Applicable Benefit

 

CARE OUTSIDE OF CALIFORNIA (Benefits provided through the BlueCard® Program for out-of-state emergency and non emergency care are provided at the participating level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider )

 

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Pediatric Vision Benefits26 – Pediatric vision benefits are available for members through the end of the month in which the member turns

  1. All pediatric vision benefits are provided through MESVision, Blue Shield’s Vision Plan Administrator.

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    Comprehensive Eye Exam12: one per calendar year

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    (includes dilation, if professionally indicated)

    Ophthalmologic

    $0

    Covered up to a maximum allowance of

    $30

    Optometric

    $0

    Covered up to a maximum allowance of

    $30

    • Routine ophthalmologic exam with refraction – new patient (S0620)

    • Routine ophthalmologic exam with refraction – established patient (S0621)

    • New patient exam (92002/92004)

    • Established patient exam (92012/92014)

     

    Covered Services

    Member Copayments

     

    Participating Providers1

    Non-Participating Providers1

     

    Eyeglasses

    Lenses: one pair per calendar year

    - Lenticular (V2121, V2221, V2321)

     

    Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses.

    Polycarbonate lenses are covered in full for eligible

    members.

    $0

    Covered up to a maximum allowance of:

    $25 single vision

    $35 lined bifocal

    $45 lined trifocal

    $45 lenticular

    • Single vision (V2100-2199)

    • Conventional (lined) bifocal (V2200-2299)

    • Conventional (lined) trifocal (V2300-2399)

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    Optional Lenses and Treatments

    UV coating (standard only)

    $0

    Not covered

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    Anti-reflective coating (standard only)

    $35

    Not covered

    High-index lenses

    $30

    Not covered

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    Photochromic lenses (glass or plastic)

    $25

    Not covered

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    Polarized lenses

    $45

    Not covered

    Standard progressives

    $55

    Not covered

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    Premium progressives

    $95

    Not covered

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    Frame13 (one frame per calendar year)

    Collection frame

    $0

    Covered up to a maximum allowance

    $40

    Non-collection frames(V2020)

    Covered up to a maximum allowance

    $150

    Covered up to a maximum allowance

    $40

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    Contact Lenses14

    Elective (Cosmetic/Convenience) – standard hard(V2500, V2510)

    One pair per calendar year

    $0

    Up to $75 Maximum Allowance

    Elective (Cosmetic/Convenience) – standard soft(V2520)

    One pair per month, up to 6 months per calendar year

    $0

    Up to $75 Maximum Allowance

    Elective (Cosmetic/Convenience) – non- standard hard(V2501, V2502, V2503, V2511, V2512, V2513, V2599)

    One pair per calendar year

    $0

    Up to $75 Maximum Allowance

    Elective (Cosmetic/Convenience) – non- standard soft(V2521, V2512, V2523)

    One pair per month up to 3 months per calendar year

    $0

    Up to $75 Maximum Allowance

    Non-Elective (Medically necessary) hard or soft

    One pair per calendar year

    $0

    Up to $225 Maximum Allowance for medically necessary contact lenses

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    Supplemental low-vision testing and

    equipment15

    35%

    Not covered

    Diabetes management referral

    $0

    Not covered

     

    Other Pediatric Vision Benefits

     

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    Pediatric Dental Benefits21 – Pediatric dental benefits are available for members through the end of the month in which the member turns 19. All pediatric dental benefits are provided by Dental Benefits Providers, Blue Shield’s Dental Plan Administrator.

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    Child Dental Diagnostic and Preventive Participating Dentists Non-Participating

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    Dentists25

    Oral exam

    No charge

    20%

    Preventive - cleaning

    No charge

    20%

    Preventive - x-ray

    No charge

    20%

    Sealants per tooth

    No charge

    20%

    Topical fluoride application

    No charge

    20%

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    Caries risk management

    No charge

    20%

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    Space maintainers - fixed

    No charge

    20%

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    Amalgam fill - 1 surface23

    20%

    30%

     

    Root canal - molar

    50%

    50%

    Gingivectomy per quad

    50%

    50%

     

    Child Dental Basic Services Child Dental Major Services22

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    Covered Services

    Member Copayments

     

    Participating Providers1

    Non-Participating Providers1

    Extraction - single tooth exposed root

    or erupted

    50%

    50%

     

    Extraction - complete bony

    50%

    50%

    Porcelain with metal crown

    50%

    50%

     

    Child Orthodontics22, 24

    Medically necessary orthodontics

    50%

    50%

     

    Please Note: Benefits are subject to modification for subsequently enacted state or federal legislation.

     

    Endnotes:

    1. The member is responsible for a copayment or coinsurance from participating providers. Participating providers accept Blue Shield’s allowable amounts as full payment for covered services.

      Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield’s allowable amount. Charges above the allowable amount do not count toward the calendar year medical deductible out-of-pocket maximum.

       

    2. For family coverage, there is an individual out-of-pocket maximum within the family out-of-pocket maximum. This means that the out-of-pocket maximum will be met for an individual who meets the individual out-of-pocket maximum prior to the family meeting the family out-of-pocket maximum. Copayments or coinsurance for covered services accrue to the calendar year out-of-pocket maximum, except copayments or coinsurance for (a) charges in excess of specified benefit maximums; (b) Bariatric surgery: covered travel expenses for bariatric surgery; and (c) Dialysis center services dialysis services from a non-participating provider. Copayments, coinsurance, and charges for services not accruing to the member’s calendar year out-of-pocket maximum continue to be the member’s responsibility after the calendar year out -of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details.

       

    3. The allowable amount for non-emergency surgery and services received from a non-participating hospital or facility is limited to $500 (outpatient) or

      $2000 (inpatient) per day. Members are responsible for the coinsurance and all charges that exceed $500 (outpatient) or $2000 (inpatient) per day. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum and continue to be owed after the maximum is reached.

       

    4. Services may require prior authorization by the plan. When services are prior authorized, members pay the participating provider amount.

       

    5. The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center is $300 per day. Members are responsible for the coinsurance and all charges in excess of $300 per day. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum and continue to be owed after the maximum is reached.

       

    6. Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties (“Designated Counties”), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details.

       

    7. 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 a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Medicare Part D premium.

       

    8. Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and are not subject to the calendar year medical deductible. However, if a brand contraceptive is selected when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic equivalent. The difference in cost that the member must pay does not accrue to any calendar year medical or pharmacy deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. The member or physician may request a medical necessity exception to the difference in cost as further described in the Evidence of Coverage. In addition, select brand. In addition, select contraceptives may need prior authorization to be covered without a copayment.

       

    9. If a member or physician selects a brand drug when a Tier 1 drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its Tier 1 drug equivalent, as well as the applicable generic copayment. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket maximum responsibility. The member or physician may request a medical necessity exception to the difference in cost as further described in the Evidence of Coverage. Refer to the Evidence of Coverage and Summary of Benefits for details.

       

    10. Mental Health and Substance Use Disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health and Substance Use Disorder services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental Health and Substance Use Disorder services rendered by non- participating providers are administered by Blue Shield. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers.

    11. Network Specialty Pharmacies dispense Specialty Drugs which require coordination of care, close monitoring, or extensive patient training that generally cannot be met by a retail pharmacy. Network Specialty Pharmacies also dispense Specialty Drugs requiring special handling or manufacturing processes, restriction to certain Physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty Drugs are generally high cost.

       

    12. The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses.

       

    13. This benefit covers collection frames at no cost at participating independent and retail chain providers. Participating retai l chain providers typically do not display the frames as “collection,” but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64.

      Participating providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider’s charge.

       

    14. Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required.

       

      Blue Shield of California is an independent member of the Blue Shield Association A46204 –PPO (1/16)

       

    15. A report from the provider and prior authorization from the contracted VPA is required.

       

    16. Preventive health services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance.

       

    17. Specialty Drugs are available from a Network Specialty Pharmacy. A Network Specialty Pharmacy provides Specialty Drugs by mail or upon member request, at an associated retail store for pickup.

       

    18. Participating non-hospital based ("freestanding") outpatient x-ray, laboratory and pathology or radiology center may not be available in all areas. Outpatient x-ray, pathology and laboratory and radiology services may also be obtained from a hospital, an ambulatory surgery center or radiology center that is affiliated with a hospital, and paid according to the hospital services benefits.

       

    19. For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan calendar year medical deductible has been met.

       

    20. Blue Shield’s Short-Cycle Specialty Drug Program allows initial prescriptions for select Specialty Drugs to be dispensed for a 15-day trial supply, as further described in the Evidence of Coverage. In such circumstances, the applicable Specialty Drug copayment or coinsurance will be pro-rated.

       

    21. Members can search for dental network providers in the “Find a Provider” section of blueshieldca.com. All pediatric dental benefits are provided by Dental Benefits Providers, Blue Shield’s Dental Plan Administrator. Any calendar year pediatric dental services deductible, copayments and coinsurance for covered dental services accrue to the calendar year out-of-pocket maximum, including any copayments for covered orthodontia services. Charges in excess of benefit maximums and premiums do not accrue to the calendar year out -of-pocket maximum.

       

    22. There are no waiting periods for major & orthodontic services.

       

    23. Posterior composite resin, or acrylic restorations are optional services, and Blue Shield will only pay the amalgam filling rate while the Member will be responsible for the difference in cost between the posterior composite resin and amalgam filling.

       

    24. Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio -Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required.

      Those immediate qualifying conditions are:

      • Cleft lip and or palate deformities

      • Craniofacial Anomalies including the following: Crouzon’s syndrome, Treacher -Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hemi-facial hypertrophy and other severe craniofacial deformities which 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 recessio n of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program.

      • Severe traumatic deviation must be justified by attaching a descriptio n of the condition.

      • 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 HLD Index).

         

    25. For covered services rendered by non-participating dentists, the member is responsible for all charges above the Allowable Amount.

       

    26. Members can search for vision care providers in the “Find a Provider” section of blueshieldca.com. All pediatric vision benefits are provided through MESVision, Blue Shield’s Vision Plan Administrator. Any vision services deductibles, copayments and coinsurance for covered vision services accrue to the calendar year out-of-pocket maximum. Charges in excess of benefit maximums and premiums do not accrue to the calendar year

out-of-pocket maximum.

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