Medical Plans

General Info

SVUSD offers one PPO plan and two HMO plans to certificated and management employees who are scheduled to work more than 50%, and classified employees who are scheduled to work more than 30 hours per week. SVUSD offers an HMO plan to classified employees who work between 20 and 30 hours per week. Below is a brief outline of the PPO and HMO plans. For more detailed coverage and cost information, please browse the sections below.

Blue Shield of California PPO: Calendar year deductible and co-insurance and/or copayments apply. Employees and covered dependents may access physicians and hospitals of their choice. However, it is the responsibility of the employee to verify if physicians and hospitals of their choice are in-network or out-of-network. Higher copays and coinsurance apply for out-of-network services.

Blue Shield Access + HMO: Services are offered with no deductible and minimal copayments. With the HMO plan, you and your covered dependents will select your own Primary Care Physician (PCP) and medical group from the Blue Shield HMO Directory to coordinate your care. HMOs manage healthcare to ensure physicians/hospitals selected are in-network providers/facilities. There is no coverage for out-of-network services.

Blue Shield TRIO HMO: This plan offers the same coverages and costs as the Blue Shield Access + HMO, but within a narrower network of providers and facilities (in Orange County, this primarily consists of the St. Joseph's networks.) For calendar year 2018 and 2019, enrollees in the TRIO HMO plan will be provided with a Health Reimbursement Account (HRA), funded by Blue Shield, that can be used to pay for eligible medical, dental, and vision expenses. The funding amounts for employee only, employee + 1, and employee + family are $200, $400, and $600 respectively. These amounts will be prorated for mid-year enrollees.

Note: Blue Shield HMO Chiropractic services are accessed through American Specialty Health Plans. To access a provider, call 800-678-9133 and provide ASH with you first and last name and Blue Shield ID number.

Additional Services

Teledoc

The Teledoc feature won't release your PCP, but it is a convenient and affordable option for care when you're in need of care now, are considering the ER or Urgent Care, on vacation, or for short term prescription refills. Visit www.teladoc.com/bsc for call 1-800-835-2362 to register.

Shield Concierge

Shield Concierge is Blue Shield's integrated customer service model that is designed to improve and expand customer service. Through Shield Concierge, members will have access to a team that includes registered nurses, health coaches, social workers, pharmacists, pharmacy technicians, and customer service representative who will provide comprehensive information and personalized one-on-one support.

Mail Service & Specialty Pharmacy Services

CVS Caremark is the current mail service pharmacy provider and CVS Specialty will be the exclusive provider for specialty pharmacy.

Below are summaries of the benefits and coverages for the various medical plans. Accessible Alternative Version (AAV) of the available medical plans can be viewed utilizing the accordion navigation below.

Blue Shield of California PPO

Important Questions

Note: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.blueshieldca.com or by calling 1-888-235-1760.

Important QuestionsAnswersWhy This Matters:
What is the overall deductible?For preferred; $200 per individual/ $600 per family; For non-preferred: $500 per individual / $1,500 per family. Does not apply to preventative care.You must pay all the costs up to the deductible before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st).
Are there other deductibles for specific services?No.You don't have to meet deductibles for specific services, but see "Copayments for Common Medical Events" for other costs or services this plan covers.
Is there an out-of-pocket limit on my expenses?

Yes. For participating: $1,000 per individual/$3,000 per family.

For non-participating: $5,000 per individual/$15,000 per family

Prescription Drugs: For participating providers: $750 per individual/$2,250 per family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out-of-pocket limit?Premiums, balance-billed charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?No.The "Copayments for Common Medical Events" section describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?Yes. For a list of participating providers, see www.blueshieldca.com or call 1-855-256-9404If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs for covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the "Copayments for Common medical Events" section for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?No.You can see the specialist you choose without permission from this plan.
Are there services this plan doesn't cover?Yes.Some of the services this plan doesn't cover are listed in the"Excluded Services & Other Covered Services" section. See your policy or plan document for additional information about excluded services.
  • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
  • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible.
  • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference (this is called balance billing.)
  • This plan may encourage you to use participating providers by charging you lower deductibles, copayments, and coinsurance amounts.

Copayments for Common Medical Events

If you visit a health care provider's office or clinic:
Services You May NeedYour Cost if You Use a Preferred ProviderYour Cost if You Use a Non-Preferred Provider

Limitations & Exceptions
Primary Care visit to treat an injury or illness$20/visit40% coinsuranceNone
Specialist visit$20/visit40% coinsuranceNone
Other practitioner office visit$20/visit for chiropractic; $20/visit for acupuncture40% coinsurance for chiropractic; 40% coinsurance for acupunctureUp to 30 visits per calendar year for chiropractic; up to 20 visits per calendar year for acupuncture
Preventative care/screening/immunizationNo charge40% coinsuranceNone

If you have a test:
Services You May NeedYour Cost if You Use a Preferred ProviderYour Cost if You Use a Non-Preferred ProviderLimitations & Exceptions
Diagnostic test (x-ray, blood work)10% coinsurance at freestanding lab/x-ray center40% coinsurance at freestanding lab/x-ray centerNone
Imaging (CT/PET scans, MRIs)10% coinsurance at freestanding diagnostic center40% coinsurance at freestanding diagnostic center

Prior authorization is required. Failure to prior authorize may result in nonpayment of benefits.
If you need drugs to treat your illness or condition:
Services You May NeedYour Cost if You Use a Preferred ProviderYour Cost if You Use a Non-Preferred ProviderLimitations & Exceptions
Generic drugs$10/prescription (retail); $20/prescription (mail)25% coinsurance + $10/prescription (retail); Not covered (mail)Covers up to a 34-day supply (retail prescription); 35-90 day supply (mail order prescription)

Select formulary & non-formulary drugs require prior authorization.
Preferred brand drugs

$20/prescription (retail); $40/prescription (mail)

25% coinsurance + $20/prescription (retail); Not covered (mail)

Covers up to a 34-day supply (retail prescription); 35-90 day supply (mail order prescription)

Select formulary & non-formulary drugs require prior authorization.

None-preferred brand drugs

$50/prescription (retail); $100/prescription (mail)

25% coinsurance + $50/prescription (retail); Not covered (mail)

Covers up to a 34-day supply (retail prescription); 35-90 day supply (mail order prescription)

Select formulary & non-formulary drugs require prior authorization.

Specialty drugs$20/prescriptionNot coveredCovers up to a 30-day supply. Prior authorization is required.
If you have outpatient surgery:
Services You May NeedYour Cost if You Use a Preferred ProviderYour Cost if You Use a Non-Preferred ProviderLimitations & Exceptions
Facility fee (e.g.; ambulatory surgery center)

10% coinsurance

40% coinsuranceNone
Physician/surgeon fees

10% coinsurance

40% coinsuranceNone
If you need immediate medical attention:
Services You May NeedYour Cost if You Use a Preferred ProviderYour Cost if You Use a Non-Preferred ProviderLimitations & Exceptions
Emergency room services

10% coinsurance

10% coinsuranceNone
Emergency medical transportation

10% coinsurance

10% coinsuranceNone
Urgent care$20/visit at freestanding urgent care center40% coinsurance at freestanding urgent care centerNone
If you have a hospital stay:
Services You May NeedYour Cost if You Use a Preferred ProviderYour Cost if You Use a Non-Preferred ProviderLimitations & Exceptions
Facility fee (e.g.; hospital room)10% coinsurance

40% coinsurancePrior authorization is required. Failure to prior authorize may result in nonpayment of benefits.
Physician/surgeon fee

10% coinsurance

40% coinsuranceNone
If you have mental health, behavioral health, or substance abuse needs:
Services You May NeedYour Cost If You Use a Preferred ProviderYour Cost If You Use a Non-Preferred ProviderLimitations & Exceptions
Mental/Behavioral health outpatient servicesNot CoveredNot CoveredNone
Mental/Behavioral health inpatient servicesNot CoveredNot CoveredNone
Substance use disorder outpatient servicesNot CoveredNot CoveredNone
Substance use disorder inpatient servicesNot CoveredNot CoveredNone

See "Optum" tab for additional information on Mental Health and Substance benefits.

If you are pregnant:
Services You May NeedYour Cost If You Use a Preferred ProviderYour Cost If You Use a Non-Preferred ProviderLimitations & Exceptions
Prenatal and postnatal care$20/visit40% coinsuranceNone
Delivery and all inpatient services10% coinsurance40% coinsuranceNone

If you need help recovering or have other special health needs:
Services You May NeedYour Cost If You Use a Preferred ProviderYour Cost if You Use a Non-Preferred ProviderLimitations & Exceptions
Home health care10% coinsuranceNot CoveredCovers up to 100 visits per Calendar Year. Non-preferred home health care and home infusion are not covered unless pre-authorized. When these services are pre-authorized, the member pays the preferred provider copayment. Failure to prior authorize may result in nonpayment of benefits.
Rehabilitation Services10% coinsurance40% coinsuranceUp to 100 visits per Calendar Year.
Habilitation Services10% coinsurance40% coinsuranceUp to 100 visits per Calendar year.
Skilled nursing care10% coinsurance at freestanding SNF10% coinsurance at freestanding SNFCovers up to 100 prior authorized days per calendar year combined with Hospital Skilled Nursing Facility Unit. Failure to prior authorize may result in nonpayment of benefits.
Durable medical equipment10% coinsurance40% coinsurancePrior authorization is required. Failure to prior authorize may result in nonpayment of benefits.
Hospice ServiceNo ChargeNot CoveredPrior authorization is required. Failure to prior authorize may result in nonpayment of benefits. Coinsurance may apply for other hospice services.

If your child needs dental or eye care:
Services You May NeedYour Cost If You Use a Preferred ProviderYour Cost If You Use a Non-Preferred ProviderLimitations & Exceptions
Eye examNo Charge40% coinsurancenone

See "Dental" and "Vision" tabs for more information.

Excluded Services & Other Covered Services

Excluded Services & Other Covered Services

Note: The following is not a complete list. Check your policy or plan document for other excluded and covered services.

Services Your Plan Does NOT Cover
Other Covered Services
  • Cosmetic surgery
  • Dental care (Adult)
  • Infertility treatment
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Private-duty nursing
  • Routine eye care (Adult)
  • Routine foot care
  • Services not deemed medically necessary
  • Weight loss programs

  • Acupuncture
  • Bariatric surgery
  • Chiropractic care
  • Hearing aids

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending on the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-888-235-1760. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 X 61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 1-888-235-1760 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/heathreform, Additionally, a consumer assistance program can help you file your appeal. Contact California Department of Managed Health Care Help at 1-888-466-2219 or visit http://www.healthhelp.ca.gov.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standards of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:
LanguageInstructions & Phone Numbers
SpanishPara obtener asistencia en Espanol, llame al 1-866-346-7198.
TagalogKung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-346-7198.
Chinese如果需要中文的帮助,请拨打这个号码 1-866-346-7198.
Navajo (Dine)Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-7198.

Blue Shield Access+ HMO and TRIO HMO

Important Questions

Note: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.blueshieldca.com or by calling 1-888-235-1760.

Important QuestionsAnswersWhy This Matters:
What is the overall deductible?$0See the "Copayments for Common Medical Events" section for your costs for services for this plan.
Are there other deductibles for specific services?No.You don't have to meet deductibles for specific services, but see the "Copayments for Common Medical Events" section for other costs for services this plan covers.
Is there an out-of-pocket limit on my expenses?Yes. For plan providers: $1,000 per individual/$2,000 per family.The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out-of-pocket limit?Premiums, cost sharing for certain services listed in formal contract of coverage, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?No.The "Copayments for Common Medical Events" section describes limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?Yes. See www.blueshieldca.com or call 1-855-599-2656 for a list of plan providers.If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the "Copayments for Common Medical Events" section for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?Yes. Members need written approval to see a specialist except for OB/GYN or pediatrician serving as Primary Care Physician. Members may self refer using the Access+ Self Referral feature or for OB/GYN services. Please see the formal contract of coverage for details. The plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist.
Are there services this plan doesn't cover?Yes.Some of the services this plan doesn't cover are listed in the "Excluded Services & Other Covered Services" section. See you policy or plan document for additional information about excluded services.
  • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
  • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible.
  • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. for example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing).
  • This plan may encourage you to use the plan providers by charging you lower deductibles, copayments, and coinsurance amounts.

Copayments for Common Medical Events

If you visit a health care provider's office or clinic:
Services You May NeedYour Cost if You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Primary care visit to treat an injury or illness$5 copayment/visitNot CoveredFor other services received during the office visit, additional member cost-share may apply.
Specialist visit$5 copayment/visitNot CoveredFor other services received during the office visit, additional member cost-share may apply. $30 copayment per visit for Access+ Specialist Self Referral.
Other practitioner office visitChiropractic spinal manipulation: $10 copayment/visitNot CoveredCoverage for chiropractic is limited to 30 visits per calendar year. Services are provided by American Specialty Health (ASH) Network. Coverage for chiropractic appliances is limited to $50 per calendar year.
Preventative care/screening/immunizationNo ChargeNot CoveredPreventative health services are only covered when provided by plan providers. Coverage for services consistent with ACA requirements and California laws. Please refer to your plan contract for details.
If you have a test:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Diagnostic test (x-ray, blood work)

Lab & Path at Free Standing Location: No Charge

X-Ray & Imaging at Free Standing Radiology Center: No Charge

Other Diagnostic Examination at Free Standing Location: No Charge

X-Ray, Lab & Other Examination at Outpatient Hospital: No Charge

Not Covered

Benefits in this section are for diagnostic, non-preventative health services. Pre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.

Imaging (CT/PET scans, MRIs)

Radiological & Nuclear Imaging at Free Standing Radiology Center: No Charge

Radiological & Nuclear Imaging at Outpatient Hospital: No Charge

Not CoveredBenefits in this section are for diagnostic, non-preventative health services. Pre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.
If you need drugs to treat your illness or condition:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Generic drugs

Retail: $5 copayment/prescription

Mail Order: $20 copayment/prescription

Not Covered

Retail: Covers up to a 30-day supply;

Mail Order: Covers up to a 90-day supply.

Select formulary and non-formulary drugs require pre-authorization.

Brand formulary drugs

Retail: $10 copayment/prescription

Mail Order: $20 copayment/prescription

Not Covered

Retail: Covers up to a 30-day supply;

Mail Order: Covers up to a 90-day supply.

Select formulary and non-formulary drugs require pre-authorization.

Brand non-formulary drugsNot CoveredNot CoveredNone
Specialty Drugs20% coinsurance of the Blue Shield contracted rate up to $200 copayment maximum/prescriptionNot CoveredCovers up to a 30-day supply. Blue Shield's Short Cycle Specialty Drug Program allows initial prescriptions for select Specialty Drugs to be dispensed for a 15-day trial supply. In such circumstances the specialty drug copayment/coinsurance will be pro-rated. Coverage limited to drugs dispensed by select pharmacies in the Specialty Pharmacy Network unless medically necessary for a covered emergency. Pre-authorization required.

More information about prescription drug coverage is available at www.blueshieldca.com

If you have outpatient surgery:
Services You May Need: Your Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Facility Fee (e.g., ambulatory surgery center)

No Charge at a free-standing ambulatory surgery center

No Charge at a hospital-affiliated ambulatory surgery center

Not CoveredNone
Physician/surgeon feesNo ChargeNot CoveredNone
If you need immediate medical attention:
Services You May Need:Your Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Emergency room services$50 copayment/visit$50 copayment/visitCopayment waived if admitted; standard inpatient hospital facility benefits apply. This is for the hospital/facility charge only. The ER physician charge is separate. Coverage outside of California under BlueCard.
Emergency medical transportation$50 copayment/transport$50 copayment/transportNone
Urgent care

Within Plan service area: $5 copayment/visit

Outside Plan service area: $5 copayment/visit

Within Plan service area: Not Covered

Outside Plan service area: $5 copayment/visit

Pre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits. Coverage outside of California under BlueCard.
If you have a hospital stay:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Facility fee (e.g., hospital room)No ChargeNot CoveredPre-Authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.
Physician/surgeon feeNo ChargeNot CoveredNone


If you have mental health, behavioral health, or substance use disorder needs:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Mental/Behavioral health outpatient servicesServices are provided by Optum Health.
Mental/Behavioral health inpatient servicesServices are provided by Optum Health.
Substance use disorder outpatient servicesServices are provided by Optum Health.
Substance use disorder inpatient servicesServices are provided by Optum Health.

See "Optum" tab for additional coverage information.

If you are pregnant:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Prenatal and postnatal care

Prenatal: No Charge

Postnatal: No Charge

Not CoveredNone
Delivery and all inpatient servicesNo ChargeNot CoveredNone

If you need help recovering or have other special health needs:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Home health care$5 copayment/visitNot CoveredCoverage limited to 100 visits per member per calendar year. Pre-Authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.
Rehabilitation services

Office visit: $5 copayment/visit

Outpatient hospital: $5 copayment/visit

Not CoveredCoverage for physical, occupational, and respiratory therapy services.
Habilitation services

Office visit: $5 copayment/visit

Outpatient hospital: $5 copayment/visit

Not CoveredCoverage for physical, occupational, and respiratory therapy services.
Skilled nursing care

No Charge in a free-standing skilled nursing facility

No Charge in a skilled nursing unit of a hospital

Not CoveredCoverage limited to 100 days per member per benefit period combined with hospital/free-standing skilled nursing facility. Pre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.
Durable medical equipment20% coinsuranceNot CoveredNo charge for breast pump from participating providers. Pre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.
Hospice ServiceNo ChargeNot CoveredPre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.
If your child needs dental or eye care:
Services You May NeedYour Cost If You Use a Plan ProviderYour Cost If You Use a Non-Plan ProviderLimitations & Exceptions
Eye ExamNot CoveredNot CoveredNone
GlassesNot CoveredNot Covered None
Dental check-upNot CoveredNot CoveredNone

Please see "Dental" and "Vision" tabs for additional coverage information.

Excluded Services & Other Covered Services

Excluded Services & Other Covered Services

Note: The following is not a complete list. Check your policy or plan document for other excluded and covered services.

Services Your Plan Does NOT CoverOther Covered Services
  • Acupuncture
  • Cosmetic surgery
  • Dental care (Adult/Child)
  • Long-term care
  • Non-emergency/non-urgent care when traveling outside the plan service area
  • Private-duty nursing (Unless enrolled in a participating hospice program)
  • Routine eye care (Adult/Child)
  • Routing foot care (Unless for treatment of diabetes)
  • Weight loss programs
  • Bariatric surgery (Pre-authorization from primary care physician and medical plan is required. Failure to obtain pre-authorization may result in non-payment of benefits.)
  • Chiropractic care (Coverage limited to 30 visits per calendar year.)
  • Hear aids ($1,000 allowance per member every 24 months.)
  • Infertility treatment (Coverage for diagnosis and treatment of cause of infertility only.)

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending on the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-888-235-1760. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 X 61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 1-888-235-1760 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/heathreform, Additionally, a consumer assistance program can help you file your appeal. Contact California Department of Managed Health Care Help at 1-888-466-2219 or visit http://www.healthhelp.ca.gov.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standards of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:
LanguageInstructions & Phone Numbers
SpanishPara obtener asistencia en Espanol, llame al 1-866-346-7198.
TagalogKung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-346-7198.
Chinese如果需要中文的帮助,请拨打这个号码 1-866-346-7198.
Navajo (Dine)Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-7198.


Please note: Blue Shield Access+ HMO and TRIO HMO have the same benefits and coverage, but the TRIO HMO has a narrower network of providers. When checking providers with Blue Shield of California, please be sure to indicate the appropriate HMO plan.