Medi-Cal provides medical, dental, and vision coverage
San Francisco Health Plan offers members:
- Doctor Visits – 600 Primary Care Providers to choose from
- Vision Care (glasses and eye exams) – 90 vision service providers
- Hospital and Emergency Room Care – nine of the best San Francisco hospitals
- Prescription Drugs – 200+ pharmacies throughout San Francisco
- Regular Check-ups and Immunizations (shots)
- OB/GYN Services and Pregnancy Care
- Family Planning
- Mental Health Services
- Specialty Care – 2,800+ Specialists in our network
The Member Handbook should be consulted for a detailed description of coverage benefits and limitations.
The Medi-Cal Program has made changes to the program. Errata for 2019.
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. If you have questions about your benefits, call Customer Service at 1(415) 547-7800.
|Benefits||Covered Services||Member Pays|
|Professional Services||Provider visits including primary care, specialty care, inpatient and outpatient medical and surgical services.||No co-payment|
|Outpatient Services||In a physician’s office, surgery center, or other designated facility. Chemotherapy, dialysis, and radiation||No co-payment|
|Hospitalization Inpatient Services||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.||No co-payment|
|Hospital Outpatient Services||Medically necessary facility charges, general nursing care, ancillary services including operating room, prescribed drugs, laboratory, chemotherapy, and radiology.||No co-payment|
|California Children’s Services||Benefits provided through California Children’s Services (CCS) for benefits related to CCS eligible conditions.||No co-payment|
|Preventive Care||Immunizations, periodic health exams, well-child visits, STD tests, cytology exams, prenatal care.||No co-payment|
|Emergency Health Coverage||24-hour care for emergency services including psychiatric screening, examination and treatment, injury or condition requiring immediate diagnosis in and out of the Plan.||No co-payment|
|Transportation||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||No co-payment|
|Prescription Drug Coverage||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.||No co-payment|
|Mental Health Services||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.||No co-payment|
|Durable Medical Equipment||Medically necessary equipment such as crutches, wheelchairs, walkers, and home oxygen equipment that is authorized and prescribed by your SFHP provider.||No co-payment|
|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|
|Tobacco Cessation Services (Help to Quit Smoking Services)||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.
|Behavioral Health Treatment for Autism Spectrum Disorder||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 at 1(855) 371-8117 for help with finding a provider. TTY users can call 1(800) 735-2929.
|Home Health Services||Medically necessary skilled care (not custodial); nursing care, home visits, physical, occupational, and speech therapy.||No co-payment|
|Perinatal/Maternity Care||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.||No co-payment|
|Family Planning||Counseling, surgical procedures for sterilization, contraceptives, elective abortion.||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 up to one month after the month of admission.||No co-payment|
|Kidney Transplants||Medically necessary kidney transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ.||No co-payment|
|Health Education||Health education materials and classes.||No co-payment|
|Hospice||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.||No co-payment|
|Hearing Aids/Services||Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, and repairs.||No co-payment|
|Chiropractic Services||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.||No co-payment|
|Covered through your Vision Service Plan||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.||No co-payment|
|Diabetes Prevention Program||Services are offered to members 18 years of age and older and who are at risk for developing diabetes. Services are offered through the YMCA of San Francisco. SFHP covers one year of peer coach-lead classes, as well as a second year of maintenance classes for those who qualify.||No co-payment|