This manual lists benefit details including coverage criteria, benefit exclusions, limitations and exceptions for HMO IPAs and medical groups that contract with Blue Shield of California. Examples of covered services and non-covered services pertaining to that topic may also be included. You can navigate the benefit guidelines by procedure, condition or administrative topic. You'll need Adobe Reader to view the forms.
Change notification
January 2024 HMO Benefit Guidelines change notification letter (PDF, 146 KB)
Optional benefits (group plan riders)
Acupuncture/Chiropractic Services (PDF, 30 KB)
Chiropractic Services (PDF, 28 KB)
Dental HMO (PDF, 76 KB)
Dental PPO (PDF, 179 KB)
Infertility - Additional Benefits (PDF, 31 KB)
Vision Care - VPA (PDF, 28 KB)
HMO Benefit Guidelines
Download the complete manual or view individual guidelines in PDF format:
Complete manual - January 2023 HMO Benefit Guidelines (PDF, 1.1 MB)
Cross Reference Index (PDF, 73 KB)