Summary of Benefits Bronze 60 PPO AI-AN

Transcription

1 Summry of Benefits Bronze 60 PPO AI-AN Individul nd Fmily Pln PPO Benefit Pln This Summry of Benefits shows the mount you will py for Covered Services under this Blue Shield of Cliforni benefit Pln. It is only summry nd it is prt of the contrct for helth cre coverge, clled the Evidence of Coverge (EOC). 1 Plese red both documents crefully for detils. Provider Network: Exclusive PPO Network This benefit Pln uses specific network of Helth Cre Providers, clled the Exclusive PPO provider network. Providers in this network re clled Providers. You py less for Covered Services when you use Provider thn when you use Provider. You cn find Providers in this network t blueshieldc.com. Members enrolled in this benefit Pln cn lso ccess Benefits from provider or phrmcy for Ntive Americns. There is no Member cost-shring for Covered Services received from provider or phrmcy for Ntive Americns. Clendr Yer Deductibles (CYD) 2 A Clendr Yer Deductible (CYD) is the mount Member pys ech Clendr Yer before Blue Shield pys for Covered Services under the benefit Pln. Blue Shield pys for some Covered Services before the Clendr Yer Deductible is met, s noted in the Benefits chrt below. Clendr Yer medicl Individul coverge $6,300 $12,600 Deductible Fmily coverge $6,300: individul Clendr Yer phrmcy Deductible Individul coverge Clendr Yer Out-of-Pocket Mximum 6 Fmily coverge $12,600: Fmily $500 $500: individul $1,000: Fmily $12,600: individul $25,200: Fmily not covered not covered provider for Ntive : individul : Fmily : individul : Fmily An Out-of-Pocket Mximum is the most Member will py for Covered Services ech Clendr Yer. Any exceptions re listed in the Notes section t the end of this Summry of Benefits. Individul coverge $7,550 $20,000 Fmily coverge No Lifetime Benefit Mximum $7,550: individul $15,100: Fmily $20,000: individul $40,000: Fmily provider for Ntive : individul : Fmily Under this benefit pln there is no dollr limit on the totl mount Blue Shield will py for covered services in member s lifetime. Blue Shield of Cliforni is n independent member of the Blue Shield Assocition A46210-n (1/19) 1

2 First Dollr Coverge: 3 office visits per Clendr Yer This benefit Pln hs first dollr coverge () for 3 office visits with Providers. This mens Blue Shield will py for these Covered Services before you meet ny Clendr Yer Medicl Deductible. These services re identified by check mrk () in the Benefits chrt below. First dollr coverge is vilble for office visits to prticipting Physicin, prticipting Helth Cre Provider, or Mentl Helth Service Administrtor (MHSA) Provider, for ny combintion of these services: Primry cre office visit (by Primry Cre Physicin) Poditric service Specilist cre office visit Teldoc consulttion Other prctitioner office visit Urgent cre Acupuncture service Physicin home visit Outptient mentl helth nd substnce use disorder office visit After you rech the mximum number of visits under the first dollr coverge benefit, dditionl office visits in the sme Clendr Yer re subject to ny Clendr Yer medicl Deductible. First dollr coverge is provided in ddition to covered Preventive Helth Services office visits. Covered Preventive Helth Services re lso pid by Blue Shield before you meet ny Clendr Yer medicl Deductible. Benefits 7 pplies pplies pplies provider for Ntive pplies Preventive Helth Services 8 Not covered Cliforni Prentl Screening Progrm Physicin services Primry cre office visit $75/visit 50% Specilist cre office visit $105/visit 50% Physicin home visit $75/visit 50% Physicin or surgeon services in n Outptient Fcility Physicin or surgeon services in n inptient fcility 100% 50% 100% 50% 2

3 Benefits 7 pplies pplies pplies provider for Ntive pplies Other professionl services Other prctitioner office visit Includes nurse prctitioners, physicin ssistnts, nd therpists. $75/visit 50% Acupuncture services $75/visit 50% Chiroprctic services Not covered Not covered Not covered Teldoc consulttion $5/consult Not covered Not covered Fmily plnning Counseling, consulting, nd eduction Injectble contrceptive; diphrgm fitting, intruterine device (IUD), implntble contrceptive, nd relted procedure. Not covered Not covered Tubl ligtion Not covered Vsectomy 100% Not covered Infertility services Not covered Not covered Not covered Poditric services $105/visit 50% Pregnncy nd mternity cre 8 Physicin office visits: prentl nd initil postntl Physicin services for pregnncy termintion 50% 100% 50% 3

4 Benefits 7 pplies pplies pplies provider for Ntive pplies Emergency services Emergency room services 100% 100% If dmitted to the Hospitl, this pyment for emergency room services does not pply. Insted, you py the Provider pyment under Inptient fcility services/ Hospitl services nd sty. Emergency room Physicin services Urgent cre center services $75/visit 50% Ambulnce services 100% 100% This pyment is for emergency or uthorized trnsport. Outptient Fcility services Ambultory Surgery Center 100% $300/dy dditionl chrges Outptient deprtment of Hospitl: surgery 100% $500/dy dditionl chrges Outptient deprtment of Hospitl: tretment of illness or injury, rdition therpy, chemotherpy, nd necessry supplies 100% $500/dy dditionl chrges 4

5 Benefits 7 pplies pplies pplies provider for Ntive pplies Inptient fcility services Hospitl services nd sty 100% Trnsplnt services This pyment is for ll covered trnsplnts except tissue nd kidney. For tissue nd kidney trnsplnt services, the pyment for Inptient fcility services/ Hospitl services nd sty pplies. Specil trnsplnt fcility inptient services Physicin inptient services $500/dy dditionl chrges 100% Not covered 100% Not covered 5

6 Benefits 7 pplies pplies pplies provider for Ntive pplies Britric surgery services, designted Cliforni counties This pyment is for britric surgery services for residents of designted Cliforni counties. For britric surgery services for residents of non-designted Cliforni counties, the pyments for Inptient fcility services/ Hospitl services nd sty nd Physicin inptient nd surgery services pply for inptient services; or, if provided on n outptient bsis, the Outptient Fcility services nd Outptient Physicin services pyments pply. Inptient fcility services 100% Not covered Outptient Fcility services 100% Not covered Physicin services 100% Not covered 6

7 Benefits 7 pplies pplies pplies provider for Ntive pplies Dignostic x-ry, imging, pthology, nd lbortory services This pyment is for Covered Services tht re dignostic, non-preventive Helth Services, nd dignostic rdiologicl procedures, such s CT scns, MRIs, MRAs, nd PET scns. For the pyments for Covered Services tht re considered Preventive Helth Services, see Preventive Helth Services. Lbortory services Includes dignostic Ppnicolou (Pp) test. Lbortory center $40/visit 50% Outptient deprtment of Hospitl X-ry nd imging services Includes dignostic mmmogrphy. Outptient rdiology center Outptient deprtment of Hospitl $40/visit $500/dy dditionl chrges 100% 50% 100% $500/dy dditionl chrges 7

8 Benefits 7 Other outptient dignostic testing Testing to dignose illness or injury such s vestibulr function tests, EKG, ECG, crdic monitoring, non-invsive vsculr studies, sleep medicine testing, muscle nd rnge of motion tests, EEG, nd EMG. pplies pplies pplies provider for Ntive Office loction 100% 50% Outptient deprtment of Hospitl Rdiologicl nd nucler imging services Outptient rdiology center Outptient deprtment of Hospitl 100% $500/dy dditionl chrges 100% 50% 100% $500/dy dditionl chrges pplies Rehbilittive nd Hbilittive Services Includes Physicl Therpy, Occuptionl Therpy, Respirtory Therpy, nd Speech Therpy services. There is no visit limit for Rehbilittive or Hbilittive Services. Office loction $75/visit 50% Outptient deprtment of Hospitl $75/visit $500/dy dditionl chrges 8

9 Benefits 7 pplies pplies pplies provider for Ntive pplies Durble medicl equipment (DME) DME 100% 50% Brest pump Not covered Orthotic equipment nd devices Prosthetic equipment nd devices Home helth services 100% 50% 100% 50% Up to 100 visits per Member, per Clendr Yer, by home helth cre gency. All visits count towrds the limit, including visits during ny pplicble Deductible period, except hemophili nd home infusion nursing visits. Home helth gency services Includes home visits by nurse, Home Helth Aide, medicl socil worker, physicl therpist, speech therpist, or occuptionl therpist. Home visits by n infusion nurse Home helth medicl supplies Home infusion gency services Hemophili home infusion services Includes blood fctor products. 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 9

10 Benefits 7 pplies pplies pplies provider for Ntive pplies Skilled Nursing Fcility (SNF) services Up to 100 dys per Member, per Benefit Period, except when provided s prt of Hospice progrm. All dys count towrds the limit, including dys during ny pplicble Deductible period nd dys in different SNFs during the Clendr Yer. Freestnding SNF 100% 100% Hospitl-bsed SNF 100% $500/dy dditionl chrges Hospice progrm services Not covered Includes pre-hospice consulttion, routine home cre, 24-hour continuous home cre, short-term inptient cre for pin nd symptom mngement, nd inptient respite cre. Other services nd supplies Dibetes cre services Devices, equipment, nd supplies Self-mngement trining Dilysis services 100% PKU product formuls nd Specil Food Products 100% 50% 50% $300/dy dditionl chrges 100% 100% 10

11 Benefits 7 Allergy serum billed seprtely from n office visit pplies pplies pplies provider for Ntive 100% 50% pplies Mentl Helth nd Substnce Use Disorder Benefits Mentl helth nd substnce use disorder Benefits re provided through Blue Shield's Mentl Helth Services Administrtor (MHSA). MHSA pplies pplies MHSA pplies provider for Ntive pplies Outptient services Office visit, including Physicin office visit Other outptient services, including intensive outptient cre, Behviorl Helth Tretment for pervsive developmentl disorder or utism in n office setting, home, or other non-institutionl fcility setting, nd office-bsed opioid tretment Prtil Hospitliztion Progrm Psychologicl Testing $75/visit 50% $75/visit $75/visit $75/visit 50% $500/dy dditionl chrges 50% Inptient services Physicin inptient services 100% 50% 11

12 Mentl Helth nd Substnce Use Disorder Benefits Mentl helth nd substnce use disorder Benefits re provided through Blue Shield's Mentl Helth Services Administrtor (MHSA). MHSA pplies pplies MHSA pplies provider for Ntive pplies Hospitl services 100% $500/dy dditionl chrges Residentil Cre 100% $500/dy dditionl chrges Prescription Drug Benefits 9,10 Phrmcy Network: Rx Ultr Drug Formulry: Stndrd Formulry A seprte Clendr Yer phrmcy Deductible pplies. Phrmcy 3 pplies Phrmcy 4 pplies phrmcy for Ntive pplies Retil phrmcy prescription Drugs Per prescription, up to 30-dy supply. Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs (excluding Specilty Drugs) $500/ prescription $500/ prescription $500/ prescription $500/ prescription Not covered Not covered Not covered Not covered Contrceptive Drugs nd devices Not covered 12

13 Prescription Drug Benefits 9,10 Phrmcy Network: Rx Ultr Drug Formulry: Stndrd Formulry A seprte Clendr Yer phrmcy Deductible pplies. Phrmcy 3 pplies Phrmcy 4 pplies phrmcy for Ntive pplies Mil service phrmcy prescription Drugs Per prescription, up to 90-dy supply. Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs (excluding Specilty Drugs) $1500/ prescription $1500/ prescription $1500/ prescription $1500/ prescription Not covered Not covered Not covered Not covered Contrceptive Drugs nd devices Not covered Specilty Drugs Per prescription. Specilty Drugs re covered t tier 4 nd only when dispensed by Network Specilty Phrmcy. Orl Anticncer Drugs Per prescription, up to 30-dy supply. $500/ prescription $200/ prescription Not covered Not covered 13

14 Peditric Benefits Peditric Benefits re vilble through the end of the month in which the Member turns 19. Dentist 3 pplies Dentist 4 pplies dentist for Ntive pplies Peditric dentl 11 Dignostic nd preventive services Orl exm 10% Preventive clening 10% Preventive x-ry 10% Selnts per tooth 10% Topicl fluoride ppliction 10% Spce mintiners - fixed 10% Bsic services Restortive procedures 20% 30% Periodontl mintennce 20% 30% Mjor services Orl surgery 50% 50% Endodontics 50% 50% Periodontics (other thn mintennce) 50% 50% Crowns nd csts 50% 50% Prosthodontics 50% 50% Orthodontics (Mediclly Necessry) 50% 50% Peditric Benefits Peditric Benefits re vilble through the end of the month in which the Member turns 19. pplies pplies provider for Ntive pplies Peditric vision 12 Comprehensive eye exmintion One exm per Clendr Yer. Ophthlmologic visit Optometric visit All chrges bove $30 All chrges bove $30 14

15 Peditric Benefits Peditric Benefits re vilble through the end of the month in which the Member turns 19. pplies pplies provider for Ntive pplies Eyewer/mterils One eyeglss frme nd eyeglss lenses, or contct lenses insted of eyeglsses, up to the Benefit per Clendr Yer. Any exceptions re noted below. Contct lenses elective (Mediclly Necessry) - hrd or soft Up to two pirs per eye per Clendr Yer. Elective (cosmetic/convenience) Stndrd nd nonstndrd, hrd Up to 3 month supply for ech eye per Clendr Yer bsed on lenses selected. Stndrd nd nonstndrd, soft Up to 6 month supply for ech eye per Clendr Yer bsed on lenses selected. Eyeglss frmes Collection frmes collection frmes Eyeglss lenses Lenses include choice of glss or plstic lenses, ll lens powers (single vision, bifocl, trifocl, lenticulr), fshion or grdient tint, scrtch coting, oversized, nd glss-grey #3 prescription sunglsses. All chrges bove $150 Single vision All chrges bove $225 All chrges bove $75 All chrges bove $75 All chrges bove $40 All chrges bove $40 All chrges bove $25 All chrges bove $150 15

16 Peditric Benefits Peditric Benefits re vilble through the end of the month in which the Member turns 19. pplies pplies provider for Ntive pplies Lined bifocl Lined trifocl Lenticulr Optionl eyeglss lenses nd tretments Ultrviolet protective coting (stndrd only) All chrges bove $35 All chrges bove $45 All chrges bove $45 Not covered Polycrbonte lenses Not covered Stndrd progressive lenses Not covered Premium progressive lenses $95 Not covered Anti-reflective lens coting (stndrd only) $35 Not covered Photochromic - glss lenses $25 Not covered Photochromic - plstic lenses Not covered High index lenses $30 Not covered Polrized lenses $45 Not covered Low vision testing nd equipment Comprehensive low vision exm Once every 5 Clendr Yers. Not covered Low vision devices Not covered One id per Clendr Yer. Dibetes mngement referrl Not covered 16

17 Prior Authoriztion The following re some frequently-utilized Benefits tht require prior uthoriztion: Rdiologicl nd nucler imging services Mentl helth services, except outptient office visits Inptient fcility services Hospice progrm services Home helth services from Providers Peditric vision non-elective contct lenses nd low vision testing nd equipment Some prescription Drugs (see blueshieldc.com/phrmcy) Plese review the Evidence of Coverge for more bout Benefits tht require prior uthoriztion. Notes 1 Evidence of Coverge (EOC): The Evidence of Coverge (EOC) describes the Benefits, limittions, nd exclusions tht pply to coverge under this benefit Pln. Plese review the EOC for more detils of coverge outlined in this Summry of Benefits. You cn request copy of the EOC t ny time. Defined terms re in the EOC. Refer to the EOC for n explntion of the terms used in this Summry of Benefits. 2 Clendr Yer Deductible (CYD): Clendr Yer Deductible explined. A Deductible is the mount you py ech Clendr Yer before Blue Shield pys for Covered Services under the benefit Pln. If this benefit Pln hs ny Clendr Yer Deductible(s), Covered Services subject to tht Deductible re identified with check mrk () in the Benefits chrt bove. Covered Services not subject to the Clendr Yer medicl Deductible. Some Covered Services received from Providers re pid by Blue Shield before you meet ny Clendr Yer medicl Deductible. These Covered Services do not hve check mrk () next to them in the CYD pplies column in the Benefits chrt bove. First Dollr Coverge (). This benefit pln lso hs first dollr coverge. See the section on first dollr coverge for office visits tht re lso pid by Blue Shield before you meet ny Clendr Yer medicl Deductible. Covered Services with first dollr coverge re identified with check mrk () in the pplies column in the Benefits chrt bove. This benefit pln hs seprte Deductibles for: medicl Deductible nd phrmcy Deductible Provider Deductible nd Provider Deductible Fmily coverge hs n individul Deductible within the Fmily Deductible. This mens tht the Deductible will be met for n individul with Fmily coverge who meets the individul Deductible prior to the Fmily meeting the Fmily Deductible within Clendr Yer. 17

18 Notes 3 Using Providers: Providers hve contrct to provide helth cre services to Members. When you receive Covered Services from Provider, you re only responsible for the Copyment or Coinsurnce, once ny Clendr Yer Deductible hs been met. for services from Other Providers. You will py the Copyment or Coinsurnce pplicble to Providers for Covered Services received from Other Providers. However, Other Providers do not hve contrct to provide helth cre services to Members nd so re not Providers. Therefore, you will lso py ll chrges bove the Allowble Amount. This out-of-pocket expense cn be significnt. 4 Using Providers: Providers do not hve contrct to provide helth cre services to Members. When you receive Covered Services from Provider, you re responsible for both: the Copyment or Coinsurnce (once ny Clendr Yer Deductible hs been met), nd ny chrges bove the Allowble Amount (which cn be significnt). Allowble Amount is defined in the EOC. In ddition: Any Coinsurnce is determined from the Allowble Amount. Any chrges bove the Allowble Amount re not covered, do not count towrds the Out-of-Pocket Mximum, nd re your responsibility for pyment to the provider. This out-of-pocket expense cn be significnt. Some Benefits from Providers hve the Allowble Amount listed in the Benefits chrt s specific dollr ($) mount. You re responsible for ny chrges bove the Allowble Amount, whether or not n mount is listed in the Benefits chrt. 5 Using Providers for Ntive Americns: Providers for Ntive Americns provide helth cre services to Ntive Americns. Ntive Americn mens ny individul s defined in section 4(d) of the Indin Self-Determintion nd Eduction Assistnce Act (Pub. L ). Eligibility for coverge s Ntive Americn is determined by Covered Cliforni. Member pyment for services from Providers for Ntive Americns. Essentil helth benefits furnished directly by the Indin Helth Service (IHS), n Indin Tribe, Tribl Orgniztion, or n Urbn Indin Orgniztion or through referrl under contrcted helth services (ech s defined in 25 U.S.C. 1603). 6 Clendr Yer Out-of-Pocket Mximum (OOPM): fter you rech the Clendr Yer OOPM. You will continue to py ll chrges bove Benefit mximum. Essentil helth benefits count towrds the OOPM. Any Deductibles count towrds the OOPM. Any mounts you py tht count towrds the medicl or phrmcy Clendr Yer Deductible lso count towrds the Clendr Yer Out-of-Pocket Mximum. This benefit Pln hs seprte Provider OOPM nd Provider OOPM. Fmily coverge hs n individul OOPM within the Fmily OOPM. This mens tht the OOPM will be met for n individul with Fmily coverge who meets the individul OOPM prior to the Fmily meeting the Fmily OOPM within Clendr Yer. 18

19 Notes 7 Seprte Member Pyments When Multiple Covered Services re Received: Ech time you receive multiple Covered Services, you might hve seprte pyments (Copyment or Coinsurnce) for ech service. When this hppens, you my be responsible for multiple Copyments or Coinsurnce. For exmple, you my owe n office visit Copyment in ddition to n llergy serum Copyment when you visit the doctor for n llergy shot. 8 Preventive Helth Services: If you only receive Preventive Helth Services during Physicin office visit, there is no Copyment or Coinsurnce for the visit. If you receive both Preventive Helth Services nd other Covered Services during the Physicin office visit, you my hve Copyment or Coinsurnce for the visit. 9 Outptient Prescription Drug Coverge: Medicre Prt D-creditble coverge- This benefit Pln s prescription drug coverge is on verge equivlent to or better thn the stndrd benefit set by the federl government for Medicre Prt D (lso clled creditble coverge). Becuse this benefit pln s prescription drug coverge is creditble, you do not hve to enroll in Medicre Prt D while you mintin this coverge; however, you should be wre tht if you hve lter brek in this coverge of 63 dys or more before enrolling in Medicre Prt D you could be subject to pyment of higher Medicre Prt D premiums. 10 Outptient Prescription Drug Coverge: Brnd Drug coverge when Generic Drug is vilble. If you, the Physicin, or Helth Cre Provider, select Brnd Drug when Generic Drug equivlent is vilble, you re responsible for the difference between the cost to Blue Shield for the Brnd Drug nd its Generic Drug equivlent plus the tier 1 Copyment or Coinsurnce. This difference in cost will not count towrds ny Clendr Yer phrmcy Deductible, medicl Deductible, or the Clendr Yer Outof-Pocket Mximum. Request for Medicl Necessity Review. If you or your Physicin believes Brnd Drug is Mediclly Necessry, either person my request Medicl Necessity Review. If pproved, the Brnd Drug will be covered t the pplicble Drug tier Member pyment. Short-Cycle Specilty Drug progrm. This progrm llows initil prescriptions for select Specilty Drugs to be filled for 15-dy supply with your pprovl. When this occurs, the Copyment or Coinsurnce will be pro-rted. 11 Peditric Dentl Coverge: Peditric dentl benefits re provided through Blue Shield s Dentl Pln Administrtor (DPA). Orthodontic Covered Services. The Copyment or Coinsurnce for Mediclly Necessry orthodontic Covered Services pplies to course of tretment even if it extends beyond Clendr Yer. This pplies s long s the Member remins enrolled in the Pln. 12 Peditric Vision Coverge: Peditric vision benefits re provided through Blue Shield s Vision Pln Administrtor (VPA). Covered Services from Providers. There is no Copyment or Coinsurnce up to the listed Allowble Amount. You py ll chrges bove the Allowble Amount. Coverge for frmes. If frmes re selected tht re more expensive thn the Allowble Amount estblished for frmes under this Benefit, you py the difference between the Allowble Amount nd the provider s chrge. Collection frmes re covered with no Member pyment from Providers. Retil chin Providers do not usully disply the frmes s collection, but comprble selection of frmes is mintined. 19

20 Notes collection frmes re covered up to n Allowble Amount of $150; however, if the Provider uses: wholesle pricing, then the Allowble Amount will be up to $ wrehouse pricing, then the Allowble Amount will be up to $ Providers using wholesle pricing re identified in the provider directory. Benefit Plns my be modified to ensure complince with Stte nd Federl requirements. 20

21 Blue Shield of Cliforni Notice Informing Individuls bout Nondiscrimintion nd Accessibility Requirements Discrimintion is ginst the lw Blue Shield of Cliforni complies with pplicble stte lws nd federl civil rights lws, nd does not discriminte on the bsis of rce, color, ntionl origin, ncestry, religion, sex, mritl sttus, gender, gender identity, sexul orienttion, ge, or disbility. Blue Shield of Cliforni does not exclude people or tret them differently becuse of rce, color, ntionl origin, ncestry, religion, sex, mritl sttus, gender, gender identity, sexul orienttion, ge, or disbility. Blue Shield of Cliforni: Provides ids nd services t no cost to people with disbilities to communicte effectively with us such s: - Qulified sign lnguge interpreters - Written informtion in other formts (including lrge print, udio, ccessible electronic formts, nd other formts) Provides lnguge services t no cost to people whose primry lnguge is not English such s: - Qulified interpreters - Informtion written in other lnguges If you need these services, contct the Blue Shield of Cliforni Civil Rights Coordintor. If you believe tht Blue Shield of Cliforni hs filed to provide these services or discriminted in nother wy on the bsis of rce, color, ntionl origin, ncestry, religion, sex, mritl sttus, gender, gender identity, sexul orienttion, ge, or disbility, you cn file grievnce with: Blue Shield of Cliforni Civil Rights Coordintor P.O. Box El Dordo Hills, CA Phone: (844) (TTY: 711) Fx: (844) Emil: BlueShieldCivilRightsCoordintor@blueshieldc.com You cn file grievnce in person or by mil, fx, or emil. If you need help filing grievnce, our Civil Rights Coordintor is vilble to help you. You cn lso file civil rights complint with the U.S. Deprtment of Helth nd Humn Services, Office for Civil Rights electroniclly through the Office for Civil Rights Complint Portl, vilble t or by mil or phone t: U.S. Deprtment of Helth nd Humn Services 200 Independence Avenue SW. Room 509F, HHH Building Wshington, DC (800) ; TTY: (800) Blue Shield of Cliforni is n independent member of the Blue Shield Assocition A49726-DMHC (1/18) Complint forms re vilble t Blue Shield of Cliforni 50 Bele Street, Sn Frncisco, CA 94105

22 Notice of the Avilbility of Lnguge Assistnce Services Blue Shield of Cliforni blueshieldc.com

23 blueshieldc.com