Benefits and Covered Services

Medi-Cal provides medical, dental,
and vision coverage

Summary of Benefits

This chart below is to help you understand what services are provided by San Francisco Health Plan (SFHP). This chart is a summary only. You should look at the Member Handbook for a detailed description of coverage benefits and limitations. Limitations are the most that SFHP will cover in terms of cost and services. For all covered services, there are no co-payments.

See if you or your child qualifies for any of our benefits.

Doctor Visits – 600+ Primary Care Providers to choose from
Prescription Drugs – over 100 pharmacies throughout San Francisco
Family Planning
Vision Care (glasses and eye exams) – 50 vision service providers
Regular Check-ups and Immunizations (shots)
Mental Health Services
Hospital and Emergency Room Care – seven of the best San Francisco hospitals
OB/GYN Services and Pregnancy Care
Specialty Care – 3,000+ Specialists in our network
Member Handbook

The Member Handbook should be consulted for a detailed description of coverage benefits and limitations.

Summary of Benefits

Click below to view benefits.

Covered Services: Provider visits including primary care, specialty care, inpatient and outpatient medical and surgical services.

Member Pays: No co-payment

In a physician’s office, surgery center, or other designated facility. Chemotherapy, dialysis, and radiation

Member Pays: No co-payment

Medically necessary facility charges, room and board, general nursing care, ancillary services including operating room, intensive care unit, prescribed drugs, laboratory, and radiology during inpatient stay.

Member Pays: No co-payment

Medically necessary facility charges, general nursing care, ancillary services including operating room, prescribed drugs, laboratory, chemotherapy, and radiology.

Member Pays: No co-payment

Benefits provided through California Children’s Services (CCS) for benefits related to CCS eligible conditions.

Member Pays: No co-payment

Immunizations, periodic health exams, well-child visits, STD tests, cytology exams, prenatal care.

Member Pays: No co-payment

24-hour care for emergency services including psychiatric screening, examination and treatment, injury or condition requiring immediate diagnosis in and out of the Plan.

Member Pays: No co-payment

Emergency transportation such as ambulance, when medically necessary. Non-emergency medical transportation such as ambulance, litter van or wheelchair when you cannot get to your medical appointment by car, bus, train or taxi. For members under 21 years of age, non-medical transportation such as car, taxi, or bus to get to a medical appointment covered under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

Member Pays: No co-payment

Brand: 30-day supply for most medications, 90-day supply for contraceptives and medicines used to treat chronic conditions such as contraceptives, diabetes, depression, high-blood pressure, asthma, COPD, and more; Generic: 90-day supply for most medications, 30-day supply for opiate pain medications; up to 100- day supply for diabetic testing supplies; FDA-approved contraceptive drugs and devices. Inpatient drugs and drugs administered in a provider’s office are provided as a medical benefit.

Member Pays: No co-payment

Beacon Health Strategies provides psychotherapy, psychological testing when clinically indicated to evaluate a mental health condition, outpatient services for the purposes of monitoring drug therapy, and psychiatric consultation. Call Beacon Health Strategies toll-free at 1(855) 371-8117 for help with finding a provider. TTY users can call 1(800) 735-2929. SFHP covers outpatient laboratory, drugs, supplies and supplements in connection with mental health services.

Member Pays: No co-payment

Medically necessary equipment such as crutches, wheelchairs, walkers, and home oxygen equipment that is authorized and prescribed by your SFHP provider.

Member Pays: No co-payment

Therapeutic radiological services, ECG, EEG, mammography, other diagnostic laboratory and radiology tests, laboratory tests for the management of diabetes.

Member Pays: No co-payment

Services include two quit attempts per year. You are not required to take a break in between quit attempts.

Qualifying members receive:

  • 4 sessions of individual, group, or telephone counseling that are each at least 10 minutes long without prior authorization.
  • 90 days of FDA-approved tobacco cessation medications on SFHP’s formulary. You may need prior authorization for some tobacco cessation medications.

Member Pays: No co-payment

Treatment includes applied behavior analysis and other evidence-based services. These are services that have been reviewed and have been shown to work.

Behavioral Health Treatment Services must be:

  • Medically necessary; and
  • Prescribed by a licensed doctor or a licensed psychologist; and
  • Approved by the Plan; and
  • Given in a way that follows the Member’s Plan-approved treatment plan.

Call Beacon Health Strategies toll-free at1(855) 371-8117 for help with finding a provider. TTY users can call 1(800) 735-2929.

Member Pays: No co-payment

Medically necessary skilled care (not custodial); nursing care, home visits, physical, occupational, and speech therapy.

Member Pays: No co-payment

Prenatal and postnatal care, inpatient, newborn nursery care while the mother is hospitalized and for the first month and the following month of life. Genetic testing is covered for PKU only.

Member Pays: No co-payment

Counseling, surgical procedures for sterilization, contraceptives, elective abortion.

Member Pays: No co-payment

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 up to one month after the month of admission.

Member Pays: No co-payment

Medically necessary kidney transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ.

Member Pays: No co-payment

Health education materials and classes.

Member Pays: No co-payment

Medically necessary skilled care; counseling, drugs and supplies; short-term inpatient care for pain control and system management; bereavement services; physical, speech and occupational therapies; medical social services short-term inpatient and respite care.

Member Pays: No co-payment

Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, and repairs.

Member Pays: No co-payment

Benefits are offered to members 18 years of age and older through American Specialty Health, Inc. (ASH Plans of California). To find a chiropractic provider through ASH Plans of California, visit https://www.ashlink.com/ash/sfhp, or call 1-800-678-9133 or 1-877-710-2746 TDD/TTY. Treatment of back and neck pain only.

Member Pays: No co-payment

Vision benefits for children under the age of 21 years include eye exams from an Optometrist once every 24 months. Frames and lenses are covered. Vision benefits for adults age 21 years and older include eye exams from an Optometrist once every 24 months. Frames and lenses are not covered. Because of the risk that diabetes poses to vision, it is important for San Francisco Health Plan members with diabetes to get their routine eye exams. Routine dilated eye exams by VSP optometrists are covered annually every 12 months for diabetic patients. There is no limitation to the frequency of medically necessary exams by ophthalmologists, nor limitations on the treatment of abnormal retinal exams for any member.

Member Pays: No co-payment