1 Subject to referral approval.
2 Transportation trips are limited to plan-approved locations.
3 Upon discharge from the hospital or Skilled Nursing Facility.
4 $0 copay for preferred generic drugs (Tier 1) when purchased by mail order or retail (100-day supply).
5 $0 drug copay is based on the beneficiary’s low-income subsidy (LIS) level.
With a Blue Shield Promise Cal MediConnect Plan, you get Medicare and Med-Cal benefits and additional benefits valued at $5,150. The additional benefits and estimated value amounts are hearing aid benefits -$2,000, eye exams and up to $500 for eyeglasses (frames and lenses) or contact lenses every two years (benefit period) , $0 for SilverSneakers® fitness and wellness program- $600, unlimited transportation to plan-approved locations - $1,200, You are entitled to a quarterly allowance of $120 for OTC -$480, $0 PERS is a medical alert monitoring system $240. You pay $0 for each covered home meal delivery - $380. Blue Shield of California Promise Health Plan’s actuarial estimate of these benefits are assuming maximum coverage over course of 2021 for Blue Shield Promise Cal MediConnect Plan in Los Angeles and San Diego counties.
* This is not a complete list. The benefit information is a brief summary, not a complete description of benefits.
Blue Shield of California Promise Health Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. ©2019 Tivity Health, Inc. All rights reserved. Tivity Health is independent of Blue Shield of California Promise Health Plan.
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (800) 684-3332 [TTY: 711], 8 a.m. – 8 p.m., seven days a week. The call is free.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al Cal-MediConnect (800) 684-3332 [TTY: 711] de 8 a.m. – 8 p.m., los 7 días de la semana.
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電Cal-MediConnect (800) 684-3332（TTY：711) 每週七天辦公，早上8 點至晚上8 點或。
You can get this information for free in other formats, such as large print, braille or audio. Call (800) 684-3332 [TTY: 711], 8 a.m. – 8 p.m., seven days a week. The call is free.
For information on Blue Shield Promise Cal MediConnect Plan and other Cal MediConnect options for your health care, call the Department of Health Care Services at (800) 430-4263 (TTY: (800) 735-2922), or visit healthcareoptions.dhcs.ca.gov.
H0148_20_215A Accepted 09192020
Page last updated: 12/21/2020