Download Handbook for Members Outside California

MEMBER EDUCATION
Handbook for Members Outside California
A guide to making the most of your health plan benefits
Visit us at mylifepath.com
Group
Welcome to Blue Shield
and the BlueCard network
As a Blue Shield member, you’re entitled to a host of programs, services and benefits,
no matter where you are in the country. Through your Blue Shield benefits and the
BlueCard network, you have the essential support, choice and control of your health
and wellness you need at each stage of your life.
In this member handbook you’ll see how flexible your benefits are, offering a wide
range of medical and preventive care services and letting you decide which physician or hospital to use every time you need medical care. Even better, through the
BlueCard network you have access to 85 percent of all doctors and hospitals in the
United States. Throughout the United States and territories, there are 744,000 physicians and 9,400 medical facilities ready to serve you. And the BlueCard Worldwide
Network has more than 50,000 providers in more than 200 countries ready to serve
you when you need urgent or emergency care outside the United States.
We’ve designed this handbook so you can easily reference how to access health
care outside California. You’ll also find a description of the programs and services
available to you, so you can take full advantage of your health plan benefits.
Here are just a few of the programs and services you’ll learn about in this handbook:
• www.mylifepath.com delivers empowering health and personalized benefits
information to you wherever you are.
• Lifepath Advisers SM provides telephone access to nurses and counselors 24 hours
a day in a comprehensive program to help you keep life’s everyday problems
from becoming big.
• First StepsSM Prenatal Education Program is a helpful pregnancy and childbirth
education program that gives practical advice and information to new parents.
As a not-for-profit health plan, we will continue to use our resources to look for
other innovative ways to serve you and your family.
For complete information about the coverage and specific benefits you’ll receive
through the BlueCard network, please refer to your Evidence of Coverage booklet.
If you use a provider in the BlueCard network, many services are available to you
before you need to pay a deductible, and you’ll rarely need to bother with claim forms.
If you have any questions, don’t hesitate to call our Customer Service representatives at the phone number on your Blue Shield ID card or at (800) 200-3242 or
visit us online at www.mylifepath.com. We’re proud of the quality service we offer
our members, and we’re always ready to help you.
welcome
contents
YOUR ACCESS TO CARE AND PRESCRIPTION DRUGS
Your access to doctors and other healthcare providers
How to locate a provider in the BlueCard provider network
2
Choosing a non-BlueCard provider
3
Understanding copayments, deductibles and allowable amounts
3
About pre-authorization and case management
5
Here Are the Ways You Can Access Care
When you need preventive care and non-emergency care
7
When you need emergency care
8
When you need urgent care in the U.S. and beyond
9
When you need maternity care
10
When you need specialist care
10
When you want or need a second opinion
11
When you need inpatient hospital care
11
When you need outpatient surgery
12
When you need skilled nursing facility or home care
12
Here’s What to Do When You Need to Fill a Prescription
Ask your doctor if the medication is on our formulary
13
Go to one of the many pharmacies in our network
13
Consider our convenient mail service for maintenance drugs
14
Consider a generic equivalent
15
YOUR LIFEPATH RESOURCES FOR WELLNESS AND SUPPORT
Lifepath AdvisersTM for counselor and nurse support,
to help you face life’s challenges
16
Our comprehensive health management programs are here
when you need them
For a healthy pregnancy and childbirth
17
For managing diabetes
17
Online services give you access to the next level of information and support
Mylifepath.com, our health and benefits Web site
18
These health improvement resources can enhance your health and wellness
Mayo Clinic Guide to Self-Care
19
Men’s health publications
19
Women’s health publications
19
YOUR GUIDELINES FOR SCREENINGS AND IMMUNIZATIONS
Preventive Health Guidelines 2003/2004
20
YOUR SAFEGUARDS
Grievance and appeals process
22
Confidentiality of personal and health information
25
This document is a summary for informational purposes. It is not a contract.
The actual complete terms and conditions of the health plan are set forth in
the applicable Evidence of Coverage booklet.
YOUR ACCESS TO CARE AND PRESCRIPTION DRUGS
Your Access to Care and Prescription Drugs
Your access to doctors and other healthcare providers
No matter where you access services in the United States, the BlueCard network
gives you the freedom to choose from a wide variety of primary care providers and
specialists. The BlueCard network includes 85 percent of all doctors and hospitals
nationwide. If the doctor you choose is not in the BlueCard network, you may still
use that provider, but may be responsible for higher copayments.
Whenever possible, you should choose a doctor or hospital from the BlueCard
network. When you go to a BlueCard provider, you can save money and receive
the highest level of benefits available to you.
If you ever have a question about a provider’s network status, you can always call Customer
Service at the number shown on your Blue Shield ID card or at (800) 200-3242. Or you
can check the “find a provider” section of our Web site, www.mylifepath.com.
How to locate a provider in the BlueCard network
BlueCard network providers are physicians, hospitals and other kinds of healthcare practitioners who have contracted with a healthcare company that’s a member of the BlueCross
BlueShield Association. BlueCard providers will accept Blue Shield of California’s payment,
plus your payment of any applicable copayments and deductibles, as payment-in-full for
covered services. Your calendar-year copayment maximum is set at the lowest amount for
your plan when you access BlueCard providers.
A copayment is a percentage of charges or a fixed dollar amount that you pay when
receiving covered services. Copayments represent your share of the cost of your
covered care.
A calendar-year deductible is the dollar amount that you must pay in a calendar year
for covered services before Blue Shield begins paying its share of the cost of most of your
covered care. Some services, such as routine physical exams from BlueCard physicians,
may be available to you before you meet your calendar-year deductible. For those services, your only charge might be your copayments.
There is a limit at which you no longer need to pay copayments, in that year, for receiving
many covered services. This limit, based on a total dollar amount, is called a calendaryear copayment maximum. When you have reached that limit in a calendar year,
Blue Shield will begin paying 100 percent of our allowable amounts for those covered
services included in the calculation of your calendar-year copayment maximum, as
described in your Evidence of Coverage booklet. Please note that your calendar-year
deductible is not included in the calculation of your calendar-year copayment maximum.
Allowable amounts are the amounts that BlueCard providers agree to accept as
payment in full for covered services.
2 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
For more about copayments, deductibles and allowable amounts, see below. For more
detailed definitions, please check your Evidence of Coverage booklet.
To locate a BlueCard provider, go to the “find a provider” section of
www.mylifepath.com, select “providers outside California” and choose the
PPO option.
YOUR LIFEPATH RESOURCES
If you don’t have access to the Internet, you can call (800) 810-BLUE (2583) to locate a
BlueCard provider near you.
Choosing a non-BlueCard provider
When you decide to go to a non-BlueCard provider, you should be aware that you’ll be
responsible for paying a percentage of the amount a non-BlueCard provider charges you,
as well as the amount above Blue Shield’s allowable amount for the services you were
provided. Also, your copayments and deductibles may be higher and your calendar-year
copayment maximum is set at the highest level for your PPO plan.
If you need a claim form or have coverage questions about a bill presented to you by a
non-BlueCard provider, you can call Customer Service at the number shown on your
Blue Shield ID card or at (800) 200-3242.
For more information about copayments, copayment maximums and deductibles, see the
next section.
For detailed information about the copayments, maximums and deductibles specific to
your plan, see your Evidence of Coverage booklet.
Understanding copayments, deductibles and allowable amounts
This section contains some important definitions to help you understand your plan
and get the most of your benefits. For specific information, refer to your Evidence of
Coverage booklet.
To see personalized copayment,
deductible and other coverage
information about your health plan,
click "my health plan" on the home
page of www.mylifepath.com and log in.
PREVENTIVE HEALTH GUIDELINES
You’ll need to pay the non-BlueCard provider directly for the entire cost of your care, and
then you must file a claim with Blue Shield of California within one year of the month you
receive these services. We will keep track of these charges and apply the appropriate amount
toward your calendar-year deductible and calendar-year copayment maximum, or reimburse
you at the applicable benefit level if you’ve already met your deductible or copayment maximum for the year. We will notify you of our coverage decision within 30 days of receiving
your claim.
LEGAL INFORMATION
A copayment is a percentage of charges or a fixed dollar amount that you pay when receiving covered services. Copayments represent your share of the cost of your covered care.
Copayment percentages are based on allowable amounts. These are the amounts that
the BlueCard providers have agreed to accept as payment-in-full for covered services.
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Handbook for Members Outside California • 3
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Allowable amounts are the amount we reimburse you for covered services once you’ve
met your deductible. BlueCard providers accept the allowable amounts as full payment
for covered services. Any copayment you make will count toward your calendar-year
copayment maximum. Once you have paid up to this maximum level, you will not have
to make any additional copayments.
Allowable amounts for the same service can vary depending on where you access care.
Your Evidence of Coverage booklet provides more specific information about allowable
amounts for your plan. If you have questions not answered in your Evidence of Coverage
about an allowable amount for a particular service, you can call Customer Service at
(800) 200-3242.
As noted in the previous section, you’ll be responsible for paying a percentage of the
amount a non-BlueCard provider charges you as well as the amount above Blue Shield’s
allowable amount for the services you were provided. You should be aware that these
charges could be substantial. And please note that charges you pay above the allowable
amount are not used in the calculation of your calendar-year deductible or calendar-year
copayment maximum.
There is a limit at which you no longer need to pay copayments, in that year, for receiving
many covered services. This level, based on a dollar amount, is called a calendar-year
copayment maximum. The calendar year is defined as January 1 through December 31.
When you have reached that limit in a calendar year, Blue Shield will begin paying 100
percent of our allowable charges for many covered services. Copayments for services that
do not count toward the copayment maximum, if any, will continue to be charged after
the copayment maximum is met.
There are different calendar-year copayment maximum levels for services received from
BlueCard and non-BlueCard providers. Your calendar-year copayment maximum is higher
when you obtain services from non-BlueCard providers. You should also be aware that
there are some services that are not included in the calculation of your copayment maximum. For these services, you will need to continue to pay copayments even though you’ve
reached your copayment maximum for the year.
Most of our PPO plans have a calendar-year deductible. This is the dollar amount that
members must pay in a calendar year for covered services before Blue Shield begins paying
its share of most of the cost of your covered care. Some services, such as routine physical
exams from BlueCard physicians, may be available to you before you meet your calendaryear deductible. Please check your Evidence of Coverage for more information. For those
services, your only charge might be your copayments.
Make sure to visit www.mylifepath.com and click on “my health plan” to view specific
benefit information about copayments and deductible amounts that relate to your plan.
4 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
About preauthorization and case management
Many services may require pre-authorization. This simply means that you need to check
with Blue Shield before accessing some services. We will review the requested service
before it is actually provided to make sure it is covered by your plan. It’s important that
you understand pre-authorization and the Benefit Management Program before you
access services.
YOUR LIFEPATH RESOURCES
We created our Benefit Management Program to help our members and providers and
hospitals ensure that medical services are:
• Covered under the member’s health plan;
• Provided at the most appropriate and cost-effective level, consistent with accepted
standards of medical practice;
• Appropriate and medically necessary;
• Delivered by qualified licensed health care professionals;
• Consistent with the patient’s diagnosis and level of care required; and
• Consistent with guidelines established by the Blue Shield of California Medical Policy
Committee on Quality and Technology.
PREVENTIVE HEALTH GUIDELINES
To accomplish this, we require systematic monitoring and evaluation of the medical necessity
and level of care of services requested and provided. Medical necessity and the appropriate
level of care are determined by prospective review of requested care and services, and
concurrent and retrospective review of care that is provided. To do this, we enlist the services
of nurse reviewers, physician peer reviewers, Blue Shield of California medical directors,
peer review committees and other expert consultants.
The goal of our Benefit Management Program is to identify and correct inappropriate
utilization and to monitor the quality of care delivered to our members. In some instances,
we use care managers to provide case management for members with complex medical
needs, and those who require long-term services. Throughout case management, our care
manger will collaborate with the member and/or designated representatives, providers, and
members of the Care Management Team, to assist the member through the continuum
of care and to promote the maximum use of the member’s health plan benefits.
Obtaining pre-authorization
LEGAL INFORMATION
• You can contact our Care Management department by calling (800) 343-1691. Our care
management representatives can help you verify – before services are provided – which
health services are covered under your PPO plan, and can help you obtain those services.
Pre-service review is required for selected inpatient and outpatient services, supplies
and home medical equipment, as outlined in your Evidence of Coverage booklet.
• Pre-authorization may be required for home healthcare services and home infusion
and home injectable services.
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Handbook for Members Outside California • 5
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• Pre-authorization is required for phenylketonuria (PKU) related formulas and special
food products, certain radiological procedures and clinical trials for cancer.
• Pre-admission review is required for all inpatient hospital services, except emergencies.
You will need to notify Blue Shield within 24 hours, by the end of the first business day
after admission to a hospital, or as soon as medically possible following emergency
services. You will need to notify Blue Shield five business days prior to a scheduled
non-emergency admission.
• Pre-authorization is required for admission into a skilled nursing facility.
• Pre-authorization is required for admission into an approved hospice program.
• Transplants require pre-authorization in writing from our medical director, and the
recipient of the transplant must be a subscriber or member for benefits to be provided.
Failure to obtain prior written authorization will result in the denial of claims for
this benefit.
If you fail to contact Blue Shield of California as outlined in the “Benefits Management
Program” section of your Evidence Of Coverage booklet, or fail to follow the recommendations given to you by program administrators, you may incur an additional fee beyond
your deductibles and copayments for inpatient admissions. Also, some services may not
be covered or there may be a reduction in payment if pre-service and pre-admission review
requirements are not met.
A Blue Shield representative will respond to all requests for pre-service review, pre-authorization, and pre-admission review within five business days of receiving the request. For
urgent services – a situation in which the duration of the routine decision making process
might seriously jeopardize the life or health of the member, or when the member is
experiencing severe pain – a Blue Shield representative will respond within one business
day of receiving the request.
For more details, please refer to the “Benefits Management Program” section in your
plan’s Evidence of Coverage booklet.
6 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
Here are the ways you can access care
When you need preventive care and non-emergency care
Your preventive care, such as routine checkups and immunizations, is covered when
you go to a BlueCard provider. Preventive care is not covered when you go to a nonBlueCard provider.
YOUR LIFEPATH RESOURCES
When you go to a BlueCard provider, your annual routine physical exam – and annual
gynecological exam for women – is available to you before you meet your plan’s
deductible. You will pay only a fixed copayment, as outlined in your Evidence of Coverage
booklet. Preventive lab tests ordered during your routine health exam are also available
for an additional fixed copayment and are not subject to your deductible.
For an explanation of copayments and deductibles, see page 3.
To see which preventive services are covered under your plan, see your Evidence of Coverage
booklet. To see our Preventive Health Guidelines, turn to page 20.
For physician office visits that don’t involve preventive care or emergency care, there
is a fixed copayment or copayment percentage for seeing BlueCard providers. There is a
deductible and higher copayment percentage for seeing non-BlueCard providers, as outlined in your Evidence of Coverage booklet.
PREVENTIVE HEALTH GUIDELINES
For an office visit with a non-BlueCard provider, you must first meet your plan deductible.
If you have met it, your copayment is a percentage of Blue Shield’s allowable amount for
services received. You will also be responsible for all charges above the allowable amount.
For more information about allowable amounts, see page 3.
PPO Plan Member Identification Card
You should carry your Blue Shield member
identification (ID) card with you at all
times and show it to your physician or
other healthcare provider at the time
of your visit. Your ID card lists the
following information:
• Your name (or the name of the subscriber if different from you)
• Your identification number.
• Your employer group number
LEGAL INFORMATION
• Your effective date of coverage
• Whether or not you have the outpatient prescription drug benefit
• Some copayment information
• Your Customer Service phone number
• Your hospital preadmission and pre-service review phone number
If you lose your ID card or need additional copies for other covered family members,
please call Blue Shield Customer Service.
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Handbook for Members Outside California • 7
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When you need emergency care
Wherever you are, if you reasonably believe that you have an emergency medical condition
or mental health condition that requires an emergency response, you should seek care
at the nearest medical facility. We encourage you to call 911, when appropriate.
An emergency is defined as an unexpected medical condition, including a psychiatric
condition, that manifests as acute symptoms of sufficient severity, including severe
pain, so that the absence of immediate medical attention could reasonably be
expected to result in placing the person’s health in serious jeopardy, or serious
impairment of bodily functions, or serious dysfunction of any body organ or part.
For example, emergencies are situations where immediate medical attention is required
to prevent death or disability due to a sudden trauma or illness, such as a stroke, a broken
leg, or an acute mental health episode.
If you reasonably believe that you have an emergency medical condition or mental health
condition that requires an emergency response, you should call 911 as appropriate. You
are covered for emergency care anywhere in the world, whether you use a BlueCard
or non-BlueCard provider.
For emergency room visits that result in direct admission to the hospital, you or a family
member should notify Blue Shield within 24 hours of receiving inpatient emergency care,
by the end of the first business day following treatment, or as soon as it is medically possible to notify us. You can notify Blue Shield by calling our Care Management department
at (800) 343-1691. This phone number for inpatient hospital services also appears on your
Blue Shield ID card.
A Blue Shield representative will review the services retrospectively to determine whether
they were for a medical or mental health condition for which a reasonable person would
have believed that he or she had an emergency. If it is determined that a reasonable person
would not have believed that the condition represented an emergency, your coverage for
services you received will depend on whether you accessed care from a BlueCard hospital
or a non-BlueCard hospital. In this case, Blue Shield will notify you of its coverage decision
within 30 days of receiving the claim.
8 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
When you need urgent care in the U.S. and beyond
Urgent services are provided in response to a person's need for a prompt diagnostic
work-up and/or treatment of a medical disorder that could become an emergency if not
diagnosed and/or treated in a timely manner. If urgent services are delayed, the likely result
would be:
With the BlueCard Program, you're
covered for urgent care across the
country and around the world.
YOUR LIFEPATH RESOURCES
• prolonged yet temporary impairment,
• unwarranted prolongation of treatment, increasing the treatment risk through the
need for more complex or hazardous treatment,
• development of chronic illness,
• or extraordinary physical or psychological suffering.
For example, urgent care is needed when a condition requires prompt medical attention –
usually within 24 hours – to avoid complications and unnecessary suffering, such as
high fever or persistent diarrhea, and to keep the condition from becoming a serious
health problem.
The BlueCard Program covers your urgent care across the country and around the
world. You can locate a BlueCard provider at any time by calling (800) 810-BLUE (2583)
or by going to www.mylifepath.com. If you are located outside of the United States
you can call (804) 673-1177 collect 24 hours a day.
PREVENTIVE HEALTH GUIDELINES
We recommend bringing a list of BlueCard providers to your travel destination, rather than
waiting until you need urgent care. And you should always travel with your Blue Shield
ID card because it contains information that a BlueCard provider will need.
As part of the BlueCross BlueShield Association, BlueCard doctors and hospitals make up
one of the country’s largest provider networks. In fact, 85 percent of all providers in the
United States participate in the BlueCard Program.
When receiving urgent care from a BlueCard provider outside of California, you may be
asked to pay your copayment or deductible at the time of your visit. Once you’ve received
services from a BlueCard provider, you will be sent an Explanation of Benefits showing your
payment responsibility.
LEGAL INFORMATION
Even though the BlueCard network is extensive, there are still some remote areas where
BlueCard providers are not available. Or there may be times when a local BlueCard provider
is not available. In these instances when a BlueCard provider is unavailable, and you receive
urgent care from a provider who is not in the BlueCard network, you’ll need to submit a
claim to Blue Shield of California within one year of the month that you receive those
services. For information on how to submit a claim, refer to your Evidence of Coverage
booklet. We will make a coverage decision within 30 days of receiving your claim.
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Handbook for Members Outside California • 9
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If you access care from a provider who is not in the BlueCard network, your coverage is
at the non-preferred level outlined in your Evidence of Coverage, which includes a higher
copayment and your being responsible for any charges over Blue Shield’s allowable amount.
For more information about allowable amounts, see page 3.
You can find a BlueCard provider online by going to www.mylifepath.com and clicking
“find a provider” at the top of the page. Look for the link for providers outside California.
If you’re traveling outside the United States and its territories, click the “BlueCard Worldwide
Hospitals” link and follow the search instructions.
For information about receiving urgent inpatient hospital care outside the United States,
see the “When you need inpatient hospital care” section on page 11.
In an emergency, you should always seek care at the nearest medical facility. You are
not required to use the BlueCard program or the BlueCard Worldwide Network for
emergency care.
Whenever you receive care overseas, you should notify your physician when you return to
the United States, so he or she can provide any necessary follow-up care.
When you need maternity care
For prenatal and postnatal physician office visits, you will pay a copayment percentage of
Blue Shield’s allowable amounts for these services. Please keep in mind that you must first
meet the plan deductible and that the copayment percentage is higher when you access
these services from non-BlueCard providers. You will also be responsible for charges from
non-BlueCard providers above the allowable amount. For more information about allowable amounts, see page 3.
Covered inpatient hospital maternity services are available to you for a percentage of the
Blue Shield allowable amount, as outlined in your Evidence of Coverage booklet. Please
note that your plan may also require a copayment for hospital admissions.
You have the flexibility of
going to a specialist without
obtaining a referral.
When you need specialist care
Your plan gives you the flexibility of being able to go to a specialist, such as a
dermatologist or cardiologist, without obtaining a referral. You also have the
option of seeing a specialist who is not in the BlueCard provider network.
To keep your medical costs down, it’s wise to go to a specialist who is in the BlueCard
provider network. For information on locating a BlueCard provider, see page 2.
For an office visit with a non-BlueCard provider, your copayment is a percentage of
Blue Shield’s allowable amount for services received, after your plan deductible is met.
You will also be responsible for all charges above the allowable amount. For more information about allowable amounts, see page 3.
10 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
When you want or need a second opinion
Your plan offers the same benefits for second opinions as for other physician office visits.
For more about physician office visit benefits, see “When you need preventive care or
non-emergency care on page 2. For more specific details about your benefits, refer to
your Evidence of Coverage booklet.
YOUR LIFEPATH RESOURCES
When you need inpatient hospital care
If you need to be hospitalized, you will receive the highest level of hospitalization
benefits when you choose a BlueCard hospital.
If you receive inpatient services from a non-BlueCard hospital, you must first meet your
plan deductible before your health plan will provide any payment. If you have met it, your
copayment is a percentage of Blue Shield’s allowable amount for hospital services. You
will also be responsible for all charges above the allowable amount. For more information
about allowable amounts, see page 3.
If your inpatient services are related to emergency or urgent care services, see page 8.
Pre-authorization and pre-admission review
PREVENTIVE HEALTH GUIDELINES
For a proposed non-emergency admission, you or your physician must notify Blue Shield
at least five business days before the planned hospitalization date to receive pre-authorization. Failure to get pre-authorization from Blue Shield of California in advance of your
planned hospitalization will result in your being charged a Benefit Management Program
fee in addition to the copayments and deductibles outlined in your Evidence of Coverage
booklet. You also should contact our Customer Service department at the number listed
on your Blue Shield of California ID card or at (800) 200-3242 to verify that the inpatient
treatment or procedure that you expect to receive is covered by your health plan.
Inpatient services outside of the United States
LEGAL INFORMATION
It’s important to remember that when you use a hospital for inpatient services outside the
United States, billing may be divided into two parts. Inpatient physician services, such as
physician visits, surgery and anesthesia administration are usually billed separately from
inpatient hospital services, even at a BlueCard hospital. Hospital services can be directly
billed to Blue Shield, but you must pay for all other physician services you receive at hospitals outside the United States at the time you receive those services, and then submit a
claim within one year of the month you receive those services to Blue Shield’s Foreign Claims
Department, P.O. Box 272550, Chico, CA, 95927-2550. We will notify you of our coverage
decision within 30 days of receiving that claim. If you have any questions about foreign
claims, including what information they should contain, call Customer Service at the number
shown on your Blue Shield ID card or at (800) 200-3242.
Whenever you receive care overseas, you should notify your regular physician when you
return home, so he or she can provide any necessary follow-up care.
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Handbook for Members Outside California • 11
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When you need outpatient surgery
There are ambulatory surgery centers within the BlueCard provider network that can save
you money when you need outpatient surgery. For your plan there may be lower copayments for having outpatient surgery in a BlueCard ambulatory surgery center versus a
hospital facility. To see the cost differences, refer to your Evidence of Coverage booklet.
To help lower your healthcare costs, you may want to discuss ambulatory surgery centers
with your physician when you need outpatient surgery.
Here are the ways you can locate a preferred ambulatory surgery center:
• Go to www.mylifepath.com, click “find a provider” and look for the ambulatory
surgery option under providers outside California.
• Call (800) 810-BLUE (2583).
When you need a skilled nursing facility or home care
If you need a skilled nursing facility or home healthcare, you will receive the
highest level of benefits when you access care from skilled nursing facilities and
home healthcare providers in the BlueCard provider network.
Most of our plans require pre-authorization for home healthcare services provided
by providers who are not in our network. Your physician can help you obtain approval
for these services and can arrange for your admission to a skilled nursing facility or for
the provision of your home health care.
For complete information about your skilled nursing facility and home healthcare benefits,
see your Evidence of Coverage booklet.
To locate BlueCard skilled nursing facilities and home healthcare providers, call Customer
Service at the phone number shown on your Blue Shield ID card or at (800) 200-3242.
12 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
Here’s what to do when you need to
fill a prescription
Ask your doctor if the medication is on our formulary
The Blue Shield Drug Formulary is a tool we use to hold down medication costs. The
formulary is a comprehensive list of preferred generic and brand-name drugs recommended
by prescribing physicians. Often generic drugs are just as effective as their brand-name
equivalents. The formulary is subject to change based on quarterly reviews by physicians
and pharmacists in community practice.
Go to the "pharmacy" section of
www.mylifepath.com for detailed
information on prescription drugs
and our formulary.
YOUR LIFEPATH RESOURCES
To find out whether a drug is included in the formulary, whether a brand-name drug has
a generic equivalent, and whether a drug has coverage restrictions or prior authorization
is necessary, go to www.mylifepath.com and click the pharmacy link on the home page.
You still have access to non-formulary drugs, but some may require pre-authorization and
you will be responsible for the higher non-formulary copayment.
For a printed copy of the Blue Shield Drug Formulary, call the Customer Service number
on your Blue Shield ID card or call (800) 200-3242.
If you have a Palm OS handheld device, a personal computer and access to the Internet,
you can download a complete copy of our formulary along with valuable drug information
into your handheld device by going to www.ePoctrates.com and following the instructions.
Your physician can contact Blue Shield Pharmacy Services at (800) 535-9481 to request
prior authorization of a drug for medical necessity.
PREVENTIVE HEALTH GUIDELINES
For more information on generic and brand-name drugs, including coverage information,
see page 15.
Go to one of the many pharmacies in our network
Our pharmacy network includes all major drugstore chains. Unless you are prescribed
medication as a result of emergency care, your prescription is only covered when you fill
it at one of the pharmacies in our network. Present your Blue Shield ID card to a network
pharmacist to receive up to a 30-day supply of covered medications.
Locating a network pharmacy is easy. Go to www.mylifepath.com, click “pharmacy” in
the blue bar at the top of our home page, then click the “participating pharmacies” link
on the next page you see.
If you don’t have Internet access, you can call Customer Service at the number on your
Blue Shield ID card, or call (800) 200-3242 to find the nearest network pharmacist.
LEGAL INFORMATION
To find out about prescription copayments or the brand-name deductible for your plan,
check your Evidence of Coverage booklet or call Customer Service.
continued on next page
Handbook for Members Outside California • 13
continued from previous page
If you fill your prescription at a retail pharmacy that’s not in our network (a non-participating
pharmacy), you must pay the pharmacy for the entire cost of the prescription and then
submit a completed prescription direct reimbursement claim form for review within one
year of filling that prescription. For many of our plans, prescriptions obtained at non-participating pharmacies are only covered when they are related to emergency care. The address
for submitting the claim is printed on the claim form. You can receive a pharmacy claim
form by calling Customer Service. Unless this prescription is obtained for treatment for a
covered emergency, your cost will be higher than if you filled your prescription at one of
our network pharmacies.
About brand-name deductibles:
Your outpatient prescription coverage may be subject to a calendar-year brand-name
deductible. For example, you may need to pay up to $250 per person in a calendar year
for covered brand-name drugs before you can obtain these drugs by paying only a
copayment. To learn about your outpatient prescription coverage, and whether your
plan has a brand-name deductible, see your Evidence of Coverage booklet.
Consider our convenient mail service for maintenance drugs
If you take a particular drug for a chronic condition such as diabetes or high blood pressure
on an ongoing basis, going to the “pharmacy” at www.mylifepath.com can save you a
trip – or several trips – to your local network pharmacy. Our plans offer coverage of a mail
service benefit, available through Express Scripts. Members who take stabilized doses of
long-term maintenance medications can order a mail service refill of up to a 60-day or
90-day supply, depending on your plan.
After sending your initial maintenance drug prescription to Express Scripts, you can order
refills via the “pharmacy” section of www.mylifepath.com. If you prefer to renew your
prescription by phone, you can call Express Scripts at (800) 544-6962, or TTY (800) 9724348 if you are hearing impaired.
Allow up to 14 days for delivery from the day you mail your initial prescription order or
order a refill.
If you don’t have Internet access, call Customer Service at the number on your Blue Shield
ID card, or call (800) 200-3242 to find out more about your drug benefits and get a mail
service order form.
Please note that self-injectable drugs and oral drugs used for short-term conditions, such
as migraine medications and antibiotics, are not available through the Express Scripts
mail service.
14 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
Consider a generic equivalent
The difference between the generic versus the brand-name formulation of the same drug
is generally the price. Generics - drugs that become available when the brand-name patent
expires – offer a quality way to take control of your prescription costs. The equivalent generic
will offer the same safety and effectiveness as the brand-name version – at a cost that’s
usually four to five times lower.
YOUR LIFEPATH RESOURCES
Generic drugs, which must contain the same active ingredients in the same amounts as
their brand-name counterparts, are produced and sold under the drug’s chemical name.
They are subject to the same rigorous U.S. Food and Drug Administration (FDA) safety
and quality reviews as brand-name drugs.
It’s important to note that your copayment is higher for brand-name drugs. And if you or
your physician requests a brand-name drug when a generic is available, you are responsible
for paying the cost difference between the brand-name and generic, as well as the generic
copayment for your plan. If your prescription is for a brand-name drug that has no generic,
you will only be responsible for paying the formulary brand-name or non-formulary brandname copayment.
If you’d like to know if a drug on our formulary is available as a generic, you can check the
“pharmacy” section of our Web site, www.mylifepath.com, or call the Customer Service
number on your Blue Shield ID card.
PREVENTIVE HEALTH GUIDELINES
Your doctor and pharmacist can tell you which generics are appropriate for you.
To find out about your drug benefits, including copayments and deductibles, for your
plan, check your Evidence of Coverage booklet or call Customer Service.
LEGAL INFORMATION
Handbook for Members Outside California • 15
YOUR LIFEPATHSM RESOURCES FOR WELLNESS AND SUPPORT
Your Lifepath Resources for wellness
and support
As a Blue Shield member, you have access to a wealth of programs and services
that give you full advantage of your health plan benefits and empower you
to take control of your health and wellness at each stage of your life. We call
them Lifepath Resources, and they’re available to you on the phone, online or
in person.
Your Lifepath Resources include:
• Lifepath AdvisersSM, which offers you the services of nurses and counselors, who
provide information and support for a broad range of concerns involving physical
and emotional health, including work, family, legal, financial and educational issues.
• Health management programs that support self-care for members living with chronic
diseases and provide information to members facing the joys and challenges of childbirth and newborns.
• Online services available by registering at www.mylifepath.com, which serves as a
gateway to Lifepath Resources and guides you to personalized health and benefits
information; and RelayHealth, which offers the next level of physician support.
• Health improvement resources that supply recommendations on preventive health
care and put quick-reference self-care books in the hands of families at home.
Lifepath Advisers for counselor and nurse support,
to help you face life’s challenges
We’re proud to announce that Blue Shield has combined two types of support – personal
consultation services and nurse line services – into a comprehensive program addressing a
wide spectrum of health and wellness concerns.
With Lifepath Advisers, you can talk to registered nurses and master’s-level counselors 24
hours a day, seven days a week, to seek information, assessments and support for issues
affecting your physical and emotional health.
Lifepath Advisers is available through one toll-free phone line – 1-866-LIFEPATH. Hearing
impaired members can call our TDD line at (866) 216-9926. You can also chat online with
a registered nurse, access information, find program details and request a consultation
online by registering at www.mylifepath.com and going to the Lifepath Advisers section.
By providing truly comprehensive services and support, we believe that Lifepath Advisers
can help improve your care and wellness by helping to prevent life stresses from escalating.
Lifepath Advisers offers:
• Personal consultation services over the phone for marital and relationship issues,
family and parenting concerns, stress, grief, loss, alcohol and drug dependency and
other emotional and personal problems.
• Nurses available for healthcare assistance, self-care guidance, preparation for physician office visits, health education and practical information about chronic conditions.
This service is available over the phone or online at www.mylifepath.com.
16 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
Our comprehensive health management programs are here
when you need them
Building on research from national experts, these programs give members with chronic
conditions the tools, knowledge and support they need to better manage their health and
wellness. Our First StepsSM program offers helpful resources and useful advice to first-time
or experienced parents going through the excitement of childbirth and newborn care.
YOUR LIFEPATH RESOURCES
For more information about our health management programs, go to www.mylifepath.com
and click on “member programs” in the “health & wellness” section. Or you can call us
at (800) 244-4755 or e-mail our Center for Health Improvement at [email protected].
Please note: These health management programs are not currently available to self-funded (ASO) employers and
some other employer groups. Please check with your benefits administrator.
First Steps Prenatal Education Program
Our helpful pregnancy and childbirth education program gives practical advice and useful
information. It serves as a guide for members going through this wonderful and sometimes
overwhelming experience, from the first trimester to long after the baby comes home.
The program is also available in Spanish.
With First Steps, members receive:
• Four information-packed newsletters
PREVENTIVE HEALTH GUIDELINES
• A video on newborn care
• A personal pregnancy calendar
• A list of hospital-affiliated community organizations that provide prenatal classes
• A choice of the best-selling pregnancy and childcare books, What to Expect When
You’re Expecting or What to Expect the First Year
• A $25 “thank you” check.
For more information about First Steps, go to www.mylifepath.com and click on “member
programs” in the “health & wellness” section. Or you can call us at (800) 244-4755 or
e-mail our Center for Health Improvement at [email protected].
Chart Your Course Diabetes Management Program
Top-notch diabetes care can improve quality of life while guarding against the progressive
and dangerous complications of this disease. We offer members with diabetes our Chart
Your Course program to promote diabetes self-management skills.
LEGAL INFORMATION
Upon enrollment, we give participants the tools and skills they need, including educational
materials and schedules for hemoglobin A1c, cholesterol and complications screening, as
recommended by the American Diabetes Association. Better glucose control lowers the
risk of diabetes complications, so we also offer complimentary glucose meters to those
who need them. This program is also available in Spanish.
continued on next page
Handbook for Members Outside California • 17
continued from previous page
Online services give you access to the next level
of information and support
At Blue Shield, we’re always examining emerging technologies to determine which ones
can help achieve our goals of delivering quality benefits and premium service. You can
always count on us to find new ways to put state-of-the-art innovations to work for you.
Through our Web site we’ve become a leader in online support, information and services.
Mylifepath.com
Our comprehensive health and wellness Web site offers personalized service, support and
health information that you can access 24 hours a day, seven days a week, including:
• my health plan – Exclusively for Blue Shield members, this password-protected section
contains personalized account information. Most Blue Shield members can log on at
any time to view easy-to-understand account information, including covered benefits
and copayment amounts. You also can learn how to access care, download forms,
contact our customer service representatives and much more.
• health & wellness – This is where you get comprehensive health and wellness information from the highly respected Mayo Clinic – everything from women’s, men’s and
children’s health, to alternative medicine and more. You can also find up-to-date health
news from Reuters, the internationally recognized news agency.
• pharmacy – In this section you can search a list of formulary and non-formulary drugs
and discover generic alternatives to keep prescription costs lower. If you use our mail
service benefit, you can easily order refills or check an existing order’s status through
Express Scripts. Also, with the confidential “Ask the Pharmacist” feature, a University
of California, San Francisco, pharmacist will directly respond to your clinical questions
about medications within two business days. There’s also an archive of commonly asked
questions, so you can access general information on drug topics.
18 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
These health improvement resources can enhance
your health and wellness
We provide several helpful brochures and books to enhance the health and wellness of
our members. These resources supply recommendations on preventive healthcare, deliver
age-specific reminders for immunizations and screenings, and provide quick-reference
self-care books for home use.
YOUR LIFEPATH RESOURCES
To request one of these publications or find out more, call (800) 244-4755 or e-mail our
Center for Health Improvement at [email protected]. You also can log onto
www.mylifepath.com and click on “member programs” in the “health & wellness” section.
Mayo Clinic Guide to Self-Care
Written and reviewed by the physicians, nurses, dieticians, therapists and other professionals
at one of the most trusted and respected healthcare institutions in the world, the Mayo
Clinic Guide to Self-Care is a practical resource for answering day-to-day health questions
about more than 150 common health problems. The Mayo Clinic Guide to Self-Care also
is available in Spanish.
Men’s health publications
PREVENTIVE HEALTH GUIDELINES
In response to research that shows men are less likely to seek preventive care or report
chronic conditions, we recently launched our Men’s Health Initiative. As part of this campaign, we offer:
• A men’s health guide on several preventive health topics
• A prostate health brochure for men ages 50 and older (available in Spanish)
• A testicular cancer brochure (available in Spanish)
• A brochure on erectile dysfunction (available in Spanish)
• A testicular self-exam and prostate information shower card
Women’s health publications
We have a variety of women’s health materials that are available to our members upon
request, including Pelvic Exams: What you need to know and What Every Woman
Should Know About Breast Cancer Screening. We also offer a Breast Self-Exam shower
card, and an annual Menopause Bulletin and include health reminders based on U.S.
Preventive Services Task Force recommendations. These materials are available in both
English and Spanish.
LEGAL INFORMATION
Handbook for Members Outside California • 19
YOUR GUIDELINES FOR SCREENINGS AND IMMUNIZATIONS
2003/2004 Preventive Health Guidelines
for Healthy Children, Adolescents and Adults
Blue Shield cares about your health. That’s why we're giving you these detailed preventive health guidelines that feature
recommended health screenings, immunizations and tips for healthy living. These guidelines are developed from trusted
sources such as the U.S. Preventive Services Task Force, Advisory Committee on Immunization Practices and Centers for
Disease Control and Prevention. We keep the guidelines current by reviewing and updating them every year.
Age
IMMUNIZATIONS
Shot Number
0-2
1
DTaP (diphtheria, tetanus,
acellular pertussis)
2
4
months
Flu
6-23 months
encouraged to
receive vaccine
Hepatitis A
For age 2-18 (First dose after age 2,
second dose 6 months after first dose)
Shot Number
1
Hepatitis B
0-2 1-4
months
6-18
Shot Number
1
4
Hib (Haemophilus
influenzae Type b)
2 4 6
months
2
6
2
2
3-11
4
3
12-19
20-39
40-64
15-18
4-6
years
For high-risk individuals1 under age 50 –
annually, each autumn
Annually each autumn
for age 50 and over
For high-risk individuals2
3
3
For high-risk individuals3 (at current visit, then at 1 and 6 months)
12-15
Shot Number
1
2
3
4
IPV (inactivated
polio vaccine)
2
months
4
6-18
4-6
years
Meningococcal
College bound students and international travelers should discuss with
their doctors the risk of meningococcal disease and benefits of vaccination.
MMR (measles,
mumps, rubella)
First dose at 12-15 months, second at 4-6 years OR
at 11-12 years (if no previous second dose of MMR)
Shot Number
1
PCV (Pneumococcal
Conjugate Vaccine)
2 4 6
months
2
3
Once – MMR4 (without proof of immunity or
if no previous second dose)
4
12-15
For high-risk5
children (at
24-59 months)
Pneumococcal vaccine
Once 6
Rubella
(German measles)
Recommended for all women of childbearing age,
if rubella susceptible
Td booster
(tetanus, diphtheria)
Varicella (chickenpox)
65 AND OLDER
5
At 12-18
months
20 • Handbook for Members Outside California
Once at 11-16 years
Once every 10 years
11-12 years
(without prior immunization)
For high-risk individuals7 (2 doses, 4-8 weeks apart)
0-2
Length, weight, blood tests
and antibiotic eye drops
In the first
week of life
Height & weight checks,
vision & hearing tests
Periodically
3-11
12-19
20-39
40-64
Blood pressure
measurement
At least every 2 years
Cholesterol
(Total blood cholesterol)
Periodically (starting at age 35
for men and 45 for women)
Periodically
Age 50 and older – FOBT annually
OR FOBT annually and flexible
sigmoidoscopy every 5 years. Other
options8 include double contrast
barium enema every 5-10 years and
colonoscopy every 10 years.
Diabetes
Age 10-45, screening every 2 years, if overweight. Over age 45, screening every
3 years and more frequently if overweight.
Breast cancer
For women ages 40-69, mammogram9
every 1-2 years with an annual clinical
breast exam
Pap test – At least every 3 years beginning at age 21
or within 3 years of onset of sexual activity
Chlamydia
Recommended for all sexually active women under age 26 and for
women at high risk for infection10. Periodically, for all other women.
Rubella susceptibility
Recommended for all women of childbearing age
Osteoporosis
Evaluation of risk factors11 for women
(especially Screening postmenopausal).
Women at high risk may need
a screening test.
Pap tests can be
discontinued normal
tests, if previous
tests have been
normal
Routine
RECOMMENDATIONS FOR A HEALTHY PREGNANCY
Begin within 14 days of a confirmed pregnancy
Dietary supplements
Take 400 micrograms of folic acid to decrease the risk of fetal birth defects of the brain or spine.
Recommended calcium intake for pregnant and nursing women: 1,200-1,500 milligrams (mg) daily
Screenings and diagnostics that may be
performed in the course of prenatal care
(urine and blood tests)
Blood pressure and weight check at initial visit and all follow-up visits; screenings for chlamydia,
gestational diabetes, Group B streptococcal bacteria, Hepatitis B, syphilis, hematocrit, rubella, D (Rh)
incompatibility, alphafeto-protein, chorionic villus screening (CVS) or amniocentesis (for women 35
and older), ultrasonography, blood test for certain birth defects and HIV counseling and screening.
Discussion topics at prenatal care visits
Prior vaccinations (including flu shots), history of genital herpes, nutrition, smoking
cessation, other medication and drug use
Postpartum care
To be performed within four to six weeks following delivery
Handbook for Members Outside California • 21
LEGAL INFORMATION
Prenatal care
PREVENTIVE HEALTH GUIDELINES
Cervical cancer
YOUR LIFEPATH RESOURCES
Colorectal cancer
65 AND OLDER
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
SCREENINGS
TIPS FOR HEALTHY LIVING
Exercise
• Age 0-5 – Participate in physical activity as a family, such as taking walks or playing at the playground.
• Age 6 and up – Regular physical activity (at least 30 minutes per day starting at age 11)12 can
reduce the risks of coronary heart disease, osteoporosis, obesity and diabetes.
Nutrition
•
•
•
•
Sexual health
• STD/HIV prevention, practice safe sex (use condoms) or abstinence
• Avoid unintended pregnancy, use contraception
Substance use
•
•
•
•
•
Dental health
• Floss and brush with fluoride toothpaste daily
• Regular dental care
Breast-feeding and iron-enriched formula and foods for infants
Limit fat and cholesterol
Eat more vegetables, fruits and grain products
Recommended daily intake of calcium:
– Adolescents and young adults – 1,200-1,500 mg/day
– Women (age 25-50) and men – 1,000 mg/day
– Postmenopausal women – 1,000-1,500 mg/day
Stop smoking
Limit alcohol consumption
Don’t smoke around infants and children, second-hand smoke can harm them
Avoid illicit drug use
Avoid alcohol/drug use while driving, swimming, boating, etc.
Age 0-212 years
• Do not put baby or toddler to bed with bottle containing juice, milk or other sugary liquid. Do not prop bottle in baby’s
or toddler’s mouth. Clean baby’s gums and teeth daily.
• Use a clean, moist wash cloth to wipe gums. Use a soft toothbrush with water only, beginning with eruption of first tooth.
• Age 2 – Begin brushing child’s teeth with pea-size amount of fluoride toothpaste.
Age 512 years
• Ask dentist when and how to floss child’s teeth.
Injury prevention
•
•
•
•
•
•
•
•
•
•
Use car seats and flame retardant sleepwear for children under 5 years
Use lap-shoulder belts for children older than 5 years and adults
Always use bicycle/motorcycle/ATV helmets
Install smoke detectors and periodically check that they work
Set hot water temperature for your water heater between 120°F and 130°F
Secure window/stair guards and pool fence
Safe storage of drugs, toxic substances, firearms and matches
In case of poisoning, have syrup of ipecac and poison control phone numbers available
Get CPR training (for parents/caretakers)
Prevent falls (stair areas should be well lit, use non-slip rugs)
Topics to discuss
with your doctor
• People over 40 – Individual risks for coronary heart disease 13 and use of aspirin to prevent heart disease
• Individual risks and screening for diabetes (starting at age 10, especially if overweight)
• Women over 40 – We do not recommend the routine use of estrogen and progestin for the prevention of chronic
conditions like heart diseases in postmenopausal women. Please discuss other options with your doctor.
• Men 50 and older – Advantages and disadvantages of prostate cancer screening test
• Women 70 and older – Possible benefits of mammography
• Mental and emotional health – for example, depression and anxiety
22 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
footnotes
2
High-risk individuals for Hepatitis A include people traveling or working in countries that have high or intermediate rates of Hepatitis A, men who have
sex with men, people with chronic liver disease or clotting factor disorders and illegal drug users.
3
High-risk individuals for Hepatitis B infection include injection drug users, people who have multiple sexual partners, sexual contact with people with
HBV infection, men having sex with men, hemodialysis patients, staff and residents in institutions for the developmentally disabled, inmates of longterm correctional facilities and certain international travelers.
4
People born before 1957 are likely to have been naturally infected with measles and mumps and need not be considered
5
High-risk children for Pneumococcal Conjugate Vaccine include those with sickle cell disease and other hemoglobinopathies, congenital or acquired
asplenia or splenic dysfunction, HIV infection, immunocompromised conditions or certain chronic illnesses.
6
A second pneumococcal dose may be necessary for people 65 or older who received the vaccine more than 5 years previously and were less than 65
at the time of primary vaccination.
7
High-risk individuals for varicella infection include people with unreliable history of varicella infection or prior immunization, healthcare workers and
family contacts of immunocompromised people; teachers of young children and day care employees. Others are residents and staff institutional settings
such as colleges and correctional institutions as well as non-pregnant women of childbearing age and international travelers who do not have evidence
of immunity.
8
There is insufficient evidence to recommend one colorectal cancer screening test over the other. Please discuss with your doctor which test would be
most appropriate for you.
9
The decision to have a mammogram is an individual decision between a woman and her doctor. Based on your individual risk factors, your doctor will
help you decide when and if you should get a mammogram.
10
High-risk for chlamydia infection includes having multiple sexual partners and history of prior sexually transmitted infections.
11
There is good evidence that the risk for osteoporosis and fracture increases with age and other factors like having a personal or family history of
fracture, smoking cigarettes, low body weight, low BMI etc. Experts also recommend routine screening should begin at age 60 if a woman weighs <
154lb and doesn't take estrogen. Unless there are risk factors (like the ones above), routine screening is not recommended for women under age 65.
Please discuss your individual risks and needs with your doctor.
12
Green M, Palfrey JS, eds. 2000. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Second Edition. Arlington, VA:
National Center for Education in Maternal and Child Health.
13
People with increased risk for coronary heart disease who may benefit from aspirin therapy are men over 40, postmenopausal women and younger
people with hypertension, diabetes or a smoking habit.
susceptible.
PREVENTIVE HEALTH GUIDELINES
High-risk individuals for flu infection include people with chronic illnesses, immunocompromised individuals and healthy pregnant women who will be
in their second or third trimesters during the influenza season. Healthcare workers and people who live with or care for people at high risk for influenza
should also get a flu shot.
YOUR LIFEPATH RESOURCES
1
LEGAL INFORMATION
Handbook for Members Outside California • 23
YOUR SAFEGUARDS
Grievance and Appeals Process
Blue Shield of California has established a grievance and appeals procedure
for receiving, resolving and tracking member’s grievances and appeals with
Blue Shield.
If you are not satisfied with the Customer Service department’s response to your inquiry,
you, your provider or representative on your behalf may appeal by either:
• Calling or writing the Customer Service Department as directed in your Evidence of
Coverage booklet and requesting that they review the initial response, or
• Submitting a completed grievance form.
You may request this form from Blue Shield’s Customer Service department or by
signing on to www.mylifepath.com. You may also submit a grievance online via
www.mylifepath.com.
The completed form should be submitted to the Customer Service department at the
address noted in your Evidence of Coverage booklet. Blue Shield will acknowledge receipt
of a grievance within five calendar days.
The grievance and appeals system allows members to file grievances for at least 180 days
following any incident or action that is the subject of the enrollee’s dissatisfaction. Grievances
and appeals are resolved within 30 calendar days of Blue Shield’s receipt of your grievance
or appeal.
Expedited Decision Process
Blue Shield of California has established a procedure for our subscribers to request an
expedited decision.
• A person, physician, or representative of a person may request an expedited decision
when the routine decision-making process might seriously jeopardize the life or health
of a member, or when the member is experiencing severe pain.
• Blue Shield will make a decision and notify the member and physician within 72 hours
following the receipt of the request.
• An expedited decision may involve admissions, continued stay or other
healthcare services.
If you would like additional information regarding the expedited decision process, or if
you believe your particular situation qualifies for an expedited decision, please contact
our Customer Service department at the toll-free number listed on your Blue Shield
member ID card and in your plan’s Evidence of Coverage booklet.
24 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
For All Services
External Independent Medical Review
YOUR LIFEPATH RESOURCES
If your appeal involves a claim or services for which coverage was denied by Blue Shield
or by a contracting provider, in whole or in part, on the grounds that the service is not
medically necessary or is experimental/investigational (including the external review available under the Friedman-Knowles Experimental Treatment Act of 1996), you may choose
to make a request to the California Department of Managed Health Care to have the
matter submitted to an independent agency for external review in accordance with
California law.
• You normally must first request an appeal from Blue Shield and wait for at least 30
days before you request external review; however, if your matter would qualify for an
expedited decision as described above or involves a determination that the requested
service is experimental/investigational, you may immediately request an external review
following receipt of notice of denial.
PREVENTIVE HEALTH GUIDELINES
• You may initiate this review by completing an application for external review, a copy
of which can be obtained by contacting Customer Service. The Department of
Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a
qualified specialist for an independent determination of whether the care is medically
necessary. You may choose to submit additional records to the external review agency
for review.
• There is no cost to you for this external review. You and your physician will receive copies
of the opinions of the external review agency. This external review will be conducted
in accordance with the same normal and expedited appeal time frames stated above.
• The decision of the external review agency is binding on Blue Shield; if the external
reviewer determines that the service is medically necessary, Blue Shield will promptly
arrange for the service to be provided. This external review process is in addition to
any other procedures or remedies available to you and is completely voluntary on your
part; you are not obligated to request external review. However, failure to participate
in external review may cause you to give up any statutory right to pursue legal action
against Blue Shield regarding the disputed service.
• For more information regarding the external review process, or to request an application form, please contact Customer Service at the toll-free number shown on your
Blue Shield ID card.
LEGAL INFORMATION
continued on next page
Handbook for Members Outside California • 25
continued from previous page
The California Department of Managed Health Care is responsible for regulating health care
service plans. If you have a grievance against your health plan, you should first telephone
your health plan at (800) 200-3242 and use your health plan’s grievance process before
contacting the Department. Utilizing this grievance procedure does not prohibit any potential
legal rights or remedies that may be available to you. If you need help with a grievance
involving an emergency, a grievance that has not been satisfactorily resolved by your health
plan, or a grievance that has remained unresolved for more than 30 days, you may call the
Department for assistance. You may also be eligible for an Independent Medical Review
(IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service
or treatment, coverage decisions for treatments that are experimental or investigational in
nature and payment disputes for emergency or urgent medical services. The Department
also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891)
for the hearing and speech impaired. The Department’s Internet Web site
(http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online. The plan’s grievance process and the Department’s complaint review process
are in addition to any other dispute resolution procedures that may be available to you,
and your failure to use these processes does not preclude your use of any other remedy
provided by law.
26 • Handbook for Members Outside California
YOUR ACCESS TO CARE
AND PRESCRIPTION DRUGS
Confidentiality of Personal
and Health Information
Blue Shield of California protects the confidentiality and privacy of your personal and health
information. Personal and health information includes both medical information and
individually identifiable information, such as your name, address, telephone number and
Social Security number. We will not disclose this information, except as permitted by law.
YOUR LIFEPATH RESOURCES
A statement describing Blue Shield’s policies and procedures for preserving the
confidentiality of medical records is available and will be furnished to you upon
request. These policies and procedures are contained in our Notice of Confidentiality and
Privacy Practices, which you can obtain by calling the Customer Service number on your
Blue Shield ID card, or via www.mylifepath.com.
If you are concerned that Blue Shield may have violated your confidentiality or privacy rights,
or you disagree with a decision that we have made about access to your personal and
health information you may contact us at:
Blue Shield of California Privacy Official
P.O. Box 272540
Chico, CA 95927-2540
Toll-free telephone contact: (888) 266-8080
E-mail contact: [email protected]
PREVENTIVE HEALTH GUIDELINES
LEGAL INFORMATION
Handbook for Members Outside California • 27
A16003 (7/03)