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 2020 HMO Benefit Guidelines change notification letter (PDF, 69 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)

Substance Abuse - Optional Benefits Core Accounts (PDF, 28 KB)

Vision Care - VPA (PDF, 28 KB)

HMO Benefit Guidelines

Download the complete manual or view individual guidelines in PDF format:

Complete manual - January 2020 HMO Benefit Guidelines (PDF, 1.3 MB)

Cross Reference Index (PDF, 73 KB)

HMO Benefit Guidelines list