Benefits and Covered Services

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.

BenefitsCovered ServiceMember 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. See pages 15, 28 and 42 for detailed list of services. 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
See page 4 for detailed list of outpatient and inpatient chemical dependency and substance use disorder services
$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)