provider connection Member Name Subscriber ID Plan Name Product ID Printer-friendly QuickView Report

Transcription

1 Eligibility and Benefits Details - Provider Connection - Blue Shield of California Page 1 of 2 Information is valid and up to date as of: 3:40 PM 03/07/2015 Member Information Member Name DOB 09/03/1954 Relationship to Subscriber Subscriber/Insured Gender Male Subscriber ID Subscriber Name Current PCP Office Visit Copay XED See details Customer Service Phone No (800) Claims Mailing Address Subscriber Dues Paid To Blue Shield of California PO Box Chico, CA, /31/2015 Current Coverage - 03/01/ Present Effective Date 03/01/2015 End Date Present Cancel Date Group Number Employer Name Plan X IFP ON EXCHANGE Silver 70 PPO Current PCP Information This member does not need to select a PCP Current Deductible / Out of Pocket Limits - 03/01/ Present Annual Deductible - Year to Date 2015 Annual Deductible also includes pediatric vision, mental health, and pharmacy services (unless pharmacy deductible amount is shown separately). Medical Deductible for Preferred and Non-Preferred Provider Services Total Applies to Annual Out of Pocket Maximum Individual: $2,000 $0 Yes Family: $4,000 $0 Yes Individual: $2,000 $0 Family: $4,000 $0 Deductible accumulation is based on claims received and completed processing as of today Calculated over 12 months beginning January 1 Annual Out-of-Pocket Maximums - 03/01/ Present Annual Copayment Maximum includes medical deductible, pediatric vision, mental health, and pharmacy services. The most the member has to pay for applicable covered services. Out-of-Pocket Maximum for Participating Providers Services Individual: $6,250 $0 Family: $12,500 $0

2 Eligibility and Benefits Details - Provider Connection - Blue Shield of California Page 2 of 2 Out-of-Pocket Maximum for Preferred and Non-Preferred Provider Services Individual: $9,350 $0 Family: $18,700 $0 Out of Pocket accumulation is based on claims received and completed processing as of today. Your deductible applies toward your copayment maximum responsibility Individual Lifetime Maximum Not Applicable All Services must be a benefit of the plan and obtained while the member is eligible for plan benefits. Services may be subject to referral, authorization, or medical necessity requirements, which can vary based on the member's plan coverage.

3 Eligibility and Benefits Details Provider Connection Blue Shield of California Page 1 of 1 Member Information Information is valid and up to date as of: 3:40 PM 03/07/2015 Member Name DOB 09/03/1954 Relationship to Subscriber Subscriber/Insured Gender Male Subscriber ID Subscriber Name Subscriber Dues Paid To XED /31/2015 Customer Service Phone No (800) Pre-Admission Phone No (800) Claims Mailing Address Blue Shield of California PO Box Chico, CA, Current Coverage - 03/01/ Present Effective Date 03/01/2015 End Date Present Cancel Date Group Number Employer Name Plan X IFP ON EXCHANGE Silver 70 PPO All Services must be a benefit of the plan and obtained while the member is eligible for plan benefits. Services may be subject to referral, authorization, or medical necessity requirements, which can vary based on the member's plan coverage.

4 Blue Shield of California Page 1 of 2 Database Information Updated: 3:40 PM 03/07/2015 Detailed Benefit Information Coverage Period: 03/01/2015 to Present Printer-Friendly Benefit Summary Benefit Summary Benefit Download Pre-Existing Conditions Benefit Categories + General + Bariatric Surgery Services + Chiropractic and Acupuncture + Dental Medical Treatment + Diabetes Care + Emergencies and Urgent Care + Extra Support Services + Family Planning + Home Care + Hospice Care + Hospital Care + Infertility + Lab and Radiology/Diagnostic Testing + Medical Equipment and Supplies + Mental Health/Substance Abuse Treatment - Physician Services + Allergy + Home + In-Hospital/Facility - In-Office Anesthesia Injectable Medication Podiatrist Office Visit Second Opinion Surgery Visit/Consultation + Pregnancy/Maternity + Prescription Drugs + Preventive Care + Rehabilitative Therapy + Services Outside California + Skilled Nursing Facility + Therapeutic Services + Vision and Hearing + Womens Health Physician Services - In-Office Visit/Consultation Service Copayment Network Copayment Subject to Annual Medical Deductible? Applies to Annual Copayment Maximum? Participating Providers See details No Yes Non-Participating Providers 50% per Visit Yes Yes Additional Information about this Service Physician copayment is $45/visit. Specialist copayment is $65/visit. Copayment is not subject to deductible; copayment accrues to the copayment maximum. Category Additional Information about this Category There are no additional details for this category

5 Blue Shield of California Page 2 of 2 All Services must be a benefit of the plan and obtained while the member is eligible for plan benefits. Services may be subject to referral, authorization, or medical necessity requirements, which can vary based on the member's plan coverage.

6 Eligibility and Benefits Details - Provider Connection - Blue Shield of California Page 1 of 1 Current PCP Information Information is valid and up to date as of: 3:40 PM 03/07/2015 This member does not need to select a PCP All Services must be a benefit of the plan and obtained while the member is eligible for plan benefits. Services may be subject to referral, authorization, or medical necessity requirements, which can vary based on the member's plan coverage.

7 Blue Shield of California Page 1 of 1 Current Deductible / Out of Pocket Limits - 03/01/ Present Information is valid and up to date as of: 3:40 PM 03/07/2015 Annual Deductible - Year to Date 2015 Annual Deductible also includes pediatric vision, mental health, and pharmacy services (unless pharmacy deductible amount is shown separately). Medical Deductible for Preferred and Non-Preferred Provider Services Applies to Annual Out of Pocket Maximum Individual: $2,000 $0 Yes Family: $4,000 $0 Yes Total Individual: $2,000 $0 Family: $4,000 $0 Deductible accumulation is based on claims received and completed processing as of today Calculated over 12 months beginning January 1 Annual Out-of-Pocket Maximums - 03/01/ Present Annual Copayment Maximum includes medical deductible, pediatric vision, mental health, and pharmacy services. The most the member has to pay for applicable covered services. Out-of-Pocket Maximum for Participating Providers Services Individual: $6,250 $0 Family: $12,500 $0 Out-of-Pocket Maximum for Preferred and Non-Preferred Provider Services Individual: $9,350 $0 Family: $18,700 $0 Out of Pocket accumulation is based on claims received and completed processing as of today. Your deductible applies toward your copayment maximum responsibility Individual Lifetime Maximum Not Applicable All Services must be a benefit of the plan and obtained while the member is eligible for plan benefits. Services may be subject to referral, authorization, or medical necessity requirements, which can vary based on the member's plan coverage.