Benefits and Covered Services
Evidence of Coverage
The Evidence of Coverage should be consulted for a detailed description of coverage benefits and limitations.
See the New Consumer Protection Law Notice (AB72) for information about protection from surprise medical bills.
Note: There are no co-payments for preventive visits or for members under the age of 24 months for well-baby care and office visits. There are no co-payments for members who are documented Alaska Natives or Native Americans.
Summary of Benefits
The Summary of Benefits matrix is intended to be used to help you compare coverage benefits and is a summary only. Please see the Evidence of Coverage for a detailed description of coverage benefits and limitations.
| Benefits | Covered Service | Member Pays |
|---|---|---|
| Deductibles | No deductibles | |
| Lifetime Maximum | Unlimited | |
| Out-of-Pocket Limit | $5,000 | |
| Professional Services | In-licensed hospital, skilled nursing facility, hospice, behavioral health facility; office or home physician visit | No co-payment |
| Outpatient Services | Chemotherapy, dialysis, surgery, anesthesiology, radiation, and associated medically necessary facility charge | No co-payment |
| Hospitalization Services | Room and board, general nursing care, ancillary services including operating room, intensive care unit, prescribed drugs, laboratory, and radiology during inpatient stay | No co-payment |
| Emergency Health Coverage | 24-hour care for sudden, serious, and unexpected illness, injury, or condition requiring immediate diagnosis in and out of the Plan | No co-payment |
| Ambulance Services | Ambulance transportation when medically necessary | No co-payment |
| Prescription Drug Coverage | Prescriptions drug are covered per the SFHP Formulary. | $5 co-payment per prescription for generic drugs $10 co-payment per prescription for Brand name drugs $10 co-payment per prescription for Specialty Brand name drugs No co-payment for FDA-approved contraceptive drugs and devices |
| Durable Medical Equipment | Equipment suitable for use in the home, such as blood glucose monitors, apnea monitors, asthma-related equipment, and supplies | No co-payment |
| Behavioral Health Services | Inpatient and Outpatient services provided through the County behavioral health department with referral. | No co-payment |
| Substance Use Disorder and Chemical Dependency Services | – Outpatient visits for crisis intervention – Inpatient detoxification, substance use and chemical dependency services – Crisis intervention and outpatient alcohol or drug abuse treatment as medically necessary |
$0 No co-payments Sin copagos |
| Home Health Services | Medically necessary skilled care (not custodial); home visits, physical, occupational and speech therapy up to 100 days per year. | No co-payment |
| Hearing Aids/Services | Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, repairs | No co-payment |
| Eye Exams/ Supplies Covered through your Vision Service Plan |
Annual exams to determine the need for corrective lenses | $10 per eye exam $25 for frames under $75 every 24 months (Member is responsible for amount over $75) |
| Diagnostic X-ray and Laboratory Services | Therapeutic radiological services, ECG, EEG, mammography, other diagnostic laboratory and radiology tests, laboratory tests for the management of diabetes | No co-payment |
| Orthoses and Prostheses | Orthoses and prostheses as prescribed by SFHP providers | No co-payment |
| Skilled Nursing Facilities | Medically necessary skilled care; room and board; x-ray, laboratory, and other ancillary services; medical social services; drugs, medications, and supplies Skilled nursing services are covered from the day of admission and are limited to 100 days during any benefit year. | No co-payment |
| Hospice | Medically necessary skilled care; counseling; drugs and supplies; short term inpatient care for pain control and system management; bereavement services; homemaker services; physical, speech and occupational therapies; medical social services; short term inpatient and respite care | No co-payment |
| Transplants | Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ | No co-payment |
| Rehabilitative Therapies Inpatient |
Physical, occupational, speech therapy | No co-payment |
| Rehabilitative Therapies Outpatient |
Physical, occupational, speech therapy as medically necessary | No co-payment |
| Health Education | Health education materials | No co-payment (no limits) |