member handbook blueshieldca.com/bscbluegroove

Transcription

1 member handbook blueshieldca.com/bscbluegroove

2 With Main Groove, you get a Personal Physician from our medical provider network, and predictable, lower outof-pocket costs than with Basic Groove, plus access to providers in both the Main Groove and Basic Groove networks.

3 Welcome to the next generation of health coverage. Blue Shield of California s Main Groove offers you access to quality care at affordable, predictable costs and local, coordinated care from a select group of quality physicians. For full information about the coverage and specific benefits of Main Groove, please refer to the Evidence of Coverage and Disclosure Form (EOC&D) booklet. You may also call your dedicated Blue Groove Member Services team at (800) or (800) (for Lodi employees). Choose your Personal Physician With Main Groove, you get to choose an HMO Personal Physician from our medical provider network, who will provide and coordinate your care. Your HMO benefits You ll pay lower, more predictable copayments than in Basic Groove when you use your HMO benefits, even when you use your Access+ Specialist SM option to go directly to a specialist in the Main Groove network.* Your PPO benefits With Main Groove, you also have some PPO benefits in addition to your HMO benefits. You can go directly to a physician in the Basic Groove PPO network or a non-network provider without a referral to receive covered services. However, out-of-pocket expenses are greater when accessing PPO benefits instead of HMO benefits. Blue Shield only covers a maximum of $10,000 for outpatient services. To limit out-of-pocket expenses, you should only use your PPO benefits for low dollar services like office visits or basic lab services. It is always a good idea to contact your Blue Shield Member Services team to understand costs before accessing your PPO benefits. * See the Using your Access+ Specialist option section for more information about this program. Sutter Health providers are not included in the Blue Groove provider network (Main, Basic and Care+ Grooves).

4 How Main Groove works You select a Personal Physician from the Main Groove HMO network.* (If you or someone in your family has a chronic condition, be sure to read the information about Care+ Groove.) Choose your Personal Physician If you haven t done that already or we chose a Personal Physician for you and you d like to choose a different one here s how: Go to blueshieldca.com/bscbluegroove and click on your Blue Groove area, then the tab labeled Doctors. Select Find a Doctor Basic and Main, and Main Blue Groove, then enter a ZIP code and the doctor s last name or specialty. Call the Blue Groove Member Services team to tell them which Personal Physician you ve selected. With Main Groove, you are an equal partner in your care. To create a path to better health, you ll need help to gauge your current health and identify any health risks you may be facing. Coverage for newborns Your newborn automatically has coverage for the first 31 days of his/her date of birth under the same Groove as the mother, except for Care+ Groove, in which the newborn will be covered under Main Groove. However, you must add your newborn to your Blue Groove medical plan within the first 31 days of his/her date of birth to continue coverage without interruption by logging in to Workday or calling employeeconnect at (877) Once you complete the enrollment, your newborn will auatomatically be enrolled in Main Groove. If you wish to have your newborn covered under the Basic Groove, you must contact Blue Shield Member Services at (800) or (800) (for Lodi employees) within 90 days from your newborn s date of birth to request Basic Groove for your newborn. Manage your health and benefits online My Health Plan Log in to blueshieldca.com/bscbluegroove to access My Health Plan for important benefits information: Verify eligibility Confirm coverage effective dates for you and your family. Explore your benefits View your copayment and annual deductible amounts. View your claims Check status and view details as well as sign up for claim alerts. Contact us Find phone numbers, addresses, or send to a Blue Groove Member Services representative. Finding a PPO provider When you want to use your PPO benefits, you can find a Basic Groove provider at blueshieldca.com/ bscbluegroove. Click on your Blue Groove area, then the tab labeled Doctors. Select Find a Doctor Basic and Main, and Basic Blue Groove, then perform your search by entering a ZIP code and the doctor s last name or specialty. * Sutter Health providers are not included in the Blue Groove provider network (Main, Basic and Care+ Grooves).

5 highlights of your benefits Here are key benefits and features of Main Groove Annual deductible Maximum calendar-year copayment Lifetime maximum Annual maximum Preventive care Emergency room Laboratory and X-rays (diagnostic testing) Network Providers $0 per member $1,250 per member Unlimited Members can access outpatient services from PPO providers, at the Basic Groove benefit level, up to a $10,000 allowed amount maximum, per member, per year. No charge $100 per visit No charge Physician and authorized specialist office visit $20 per visit (Access+ Specialist $30) Hospitalization services Pregnancy and maternity (prenatal and postnatal professional physician services; for all necessary inpatient hospital services, see Hospitalization services ) Family planning care Counseling and consulting Insertion or removal of IUD IUD $250 per admission No charge No charge Durable medical equipment 20% Participating pharmacies only Contraceptive drugs & devices Retail pharmacy $10/generic $25/brand-name formulary $40/non-formulary drugs require prior authorization $0 per prescription For maintenance drugs, up to 90-day supply Participating pharmacies only Contraceptive drugs & devices From a participating specialty pharmacy only Mail order pharmacy Specialty drugs $20/generic $50/brand-name formulary $80/non-formulary drugs require prior authorization $0 per prescription 20% up to $100 copayment maximum per prescription Note: Sutter Health providers are not included in the Blue Groove provider network (Main, Basic and Care+ Grooves). Out-of-pocket expenses are greater when accessing PPO benefits instead of HMO benefits. Blue Shield only covers a maximum of $10,000 for outpatient services. To limit out-of-pocket expenses, you should only use your PPO benefits for low dollar services like office visits or basic lab services. It is always a good idea to contact your Blue Shield Member Services team to understand costs before accessing your PPO benefits.

6 Using your access+ specialist option If you want to go directly to a specialist without a referral from your Personal Physician, but you want to pay a lower copayment than with your PPO option, you can go directly to a specialist in the Main Groove network (versus the Basic Groove network). You can find a Main Groove specialist at blueshieldca.com/bscbluegroove. Click on your Blue Groove area, then on the tab labeled Doctors. Select Find a Doctor Basic and Main, and Main Blue Groove, then enter a ZIP code and the doctor s last name or specialty. When you make an appointment, be sure to tell the specialist s office staff you are using your Access+ Specialist option. For full details on the Access+ Specialist program, refer to the EOC&D booklet. More information about your pharmacy benefits Check the Main Groove formulary It s easy to access the Main Groove Drug Formulary to see if your medication is in our list of preferred prescription drugs. Once you log in to blueshieldca.com/bscbluegroove, click on Pharmacy to get to the Drug Database & Formulary. If you don t have access to the Internet or need help, simply call your dedicated Blue Groove Member Services team for personal assistance or to request a copy of the formulary. Prescriptions by mail Members who take stabilized doses of covered long-term maintenance medications for conditions such as diabetes can order a mail-service refill of up to a 90-day supply. You may save money on your copayment, and there is no charge for shipping. It s easy to get started. All you will need is a prescription from your doctor and a completed Prim New Order form. You can download the Prim New Order form by logging in to blueshieldca.com/bscbluegroove, clicking on Pharmacy, and then Mail-Service Pharmacy. Or, you can call Prim at (866) to request a form. After you send your order form and prescription to Prim , you can order refills online by going to

7 extra services and support With Main Groove, you get a wealth of extra resources to help you manage your health and make more informed healthcare decisions. NurseHelp 24/7 SM Maybe it s not a convenient time to talk to your doctor or another member of your care team? Relax. You can talk with a registered nurse anytime, day or night, to get answers to your health questions by phoning (877) That number also appears on your Main Groove member ID card. Ask the Pharmacist Maybe you have a non-urgent question about your medication, but your next appointment is a few days or weeks away? You can your question to a University of California clinical pharmacist, who will send you a private answer within two business days. Just log in to blueshieldca.com/bscbluegroove and click on Pharmacy to get to the Ask a Pharmacist section. Health Library Our website also contains a wealth of easily searchable and reliable information on just about any condition or symptom also available anytime. You ll find it in the Health & Wellness section of the Blue Groove website. Wellness discounts You can use these discounts to take a holistic approach to your health. All Blue Groove members get discounts for these services.* When you re logged in to the website, go to the Health & Wellness section to find out how to get these discounts: Weight Watchers Discounts on subscriptions, kits, meeting vouchers, and more. 24 Hour Fitness Waived fees and discounts on monthly membership dues. Alternative Care Discount Program Save at least 25% on acupuncture, chiropractic, and massage therapy services, plus discounts on wellness products. Vision services Get 20% off published retail prices when you go to discount program providers for exams, frames, lenses, and more. LASIK Get a 15% discount off LASIK and PRK corrective surgery from discount program providers. * Important note about the discount programs: These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity nor efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield health plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the EOC&D, Blue Shield reserves the right to terminate this program at any time without notice. Discount programs administered by or arranged through: Alternative Care Discount Program American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc. Vision program MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness LASIK and PRK NVision, QualSight, and TLCVision within California and TLCVision (USA) Corporation outside California

8 Getting care away from home Through the BlueCard Program, you can access emergency and urgent care services across the country and around the world when traveling. You can receive urgent care services from any provider; however, using the BlueCard Program can be more cost-effective and eliminate the need for you to pay for the services when you receive them and then submit a claim for reimbursement. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com and clicking on Providers outside CA. For Main Groove, special arrangements may be available for dependents who are full-time students; dependents of subscribers who are required by court order to provide coverage; and dependents and subscribers who are long-term travelers. Please contact your Member Services representatives to request an Away From Home Care (AFHC) Program brochure that explains these arrangements, including for how long AFHC coverage is available. Specialized health management programs Prenatal Program This program guides expectant parents from the first trimester to postnatal care, with practical advice and useful information. The program includes your choice of one of three best-selling pregnancy and parenting books and a Prenatal Guide filled with information on what to expect from the first trimester through birth and the toddler years. You will also get information on the text4baby SM * service that provides free text messages three times a week with information to help you through your pregnancy and baby s first year. Some materials are also available in Spanish. Enrolling in the program is simple. You can enroll in the Health & Wellness section after logging in to blueshieldca.com/bscbluegroove, or register by calling (877) Chronic condition management Your Main Groove offers a wide range of helpful programs for members with chronic conditions. They offer educational resources and strategies to help them manage their condition and feel better. Programs include the Asthma Program, Diabetes Program, Coronary Artery Disease(CAD) Program, Heart Failure Program, and the Chronic Obstructive Pulmonary Disease (COPD) Program. Members can apply to the programs by logging in to the Blue Groove website or by calling (866) Note: If you or someone in your family has a chronic condition, be sure to read the information about Care+ Groove on the next page. * text4baby is a service mark of the National Healthy Mothers, Healthy Babies Coalition (text4baby.org). The National Healthy Mothers, Healthy Babies Coalition has agreements with most wireless service providers to waive applicable text charges.

9 should you consider care+ groove? If you or someone in your family has one or more of these conditions, the qualifying member may be able to choose to enroll in Care+ Groove: Cancer Diabetes Heart disease Hypertension Kidney disease Osteoarthritis/Low-back pain Being in Care+ Groove means you ll have a team of specialized doctors and other caregivers who are experts in your condition, led by a Personal Physician, who will be your own physician champion toward the personalized care you need. This team will be committed to following current research-based practice guidelines for managing your condition and overall health as well as an unwavering dedication to helping you avoid the impacts and complications of these diseases. Care+ Groove Personal Physician champions will work with you and your care team to create a personalized care plan for you based on a holistic approach that considers all your health needs in light of your condition. Once this care plan is developed, you will need to do your part: You will be required to comply with the care plan to remain in Care+ Groove and take advantage of its team treatment and lower copayments. In addition to getting highly coordinated care with a more holistic approach, Care+ Groove members have lower copayments than with Main Groove, and significantly lower copays than with Basic Groove. And your condition and all medical information will be kept private between you, your physician, and your care team. If you or a covered dependent has one or more of these conditions, call Blue Groove Member Services to see about qualifying, and to enroll in Care+ Groove.

10 Notice on the availability of language assistance services to accompany vital documents issued in English We re here to help If you have any questions, visit blueshieldca.com/bscbluegroove or call your dedicated Blue Groove Member Services team from 7 a.m. to 7 p.m., Monday through Friday. Blue Groove Member Services...(800) or (800) (for Lodi employees) BlueCard Program...(800) 810-BLUE NurseHelp 24/7... (877) LifeReferrals 24/7... (800) Blue Shield of California Privacy Office... (888)

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12 An independent member of the Blue Shield Association A43806-BSC (4/13)