Benefits and Covered Services

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
Evidence of Coverage

The Evidence of Coverage should be consulted for a detailed description of coverage benefits and limitations.

Combined Evidence of Coverage and Disclosure Form – ERRATA for 2017-2018

Member Reference Guide

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 Evidence of Coverage (EOC) 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.

BenefitsCovered ServicesMember Pays
Deductibles No deductibles
Lifetime Maximum Unlimited
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.
No co-payment
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 at1(855) 371-8117 for help with finding a provider. TTY users can call 1(800) 735-2929.
No co-payment
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
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