Resource Guide, Part 1

Transcription

A Guide to CalPERS Blue Shield of California’s Health Plan
Dear Health Benefits Officer:
Knowing that the employees at your organization often look to you to help them better
understand their health benefits, we have designed a resource guide to help you answer their
questions about Blue Shield.
Enclosed is your Health Benefits Officer Resource Guide, a desktop reference to provide CalPERS
HBOs with key information about Blue Shield’s CalPERS health plan and services. With easy-to-use
tabs and a detailed table of contents, this guide has been designed to help you easily locate
key information on benefits, programs, plan highlights and resources. It is our goal to make sure
you have the most current information, so that you can best serve your employees.
What you’ll find in the HBO Resource Guide
-
Answers to Blue Shield member questions
Information regarding how your employees can earn up to $200 through Blue Shield’s
Healthy Lifestyle Rewards program
Information about benefits and special programs offered to Blue Shield members
Phone numbers, addresses, and website information
Open enrollment information
Should you have any questions, please contact our CalPERS Health Benefits Officer Priority Line
at (800) 837-4251. Dedicated service representatives are available Monday through Thursday,
8:00 a.m. to 5:00 p.m., and Friday, 9:00 a.m. to 5:00 p.m. You may also contact Blue Shield’s
Account Management team by email at calpersam@blueshieldca.com.
We look forward to partnering with you and supporting your efforts to improve employee
benefits and wellness.
Sincerely,
Ann De Rose
Senior Manager, Account Management
CalPERS Business Unit
Blue Shield
www.blueshieldca.com
A16407 (6/08)
contents
Introduction ..................................................................................................................................Page A-1
Directory
Health Benefits Officer contact information .............................................................................Page B-1
Member contact information .....................................................................................................Page B-2
Blue Shield Service Areas ………………………………………………………………………….......Page B-3
Open Enrollment
How to request a Blue Shield team member for a fair ............................................................Page C-1
How to order material .................................................................................................................Page C-1
Why Blue Shield ............................................................................................................................Page D-1
CalPERS Blue Shield Benefits
Health Maintenance Organization (HMO) Access+, NetValue HMO, EPO...........................Page E-1
How to Enroll
Annual Open Enrollment .............................................................................................................Page F-1
How to enroll-CalPERS ACES ......................................................................................................Page F-1
How to enroll with Blue Shield .....................................................................................................Page F-1
Enrolling dependents ..................................................................................................................Page F-2
Modifications for Existing Members
Changing Personal Physicians ..................................................................................................Page G-1
Continuation of coverage
COBRA .......................................................................................................................................Page G-1
Cal-COBRA ................................................................................................................................Page G-2
Workers’ compensation ...........................................................................................................Page G-3
Conversion plan .......................................................................................................................Page G-3
Leave of absence ....................................................................................................................Page G-3
Obtaining Medical Services
General care ................................................................................................................................Page H-1
Emergency care ..........................................................................................................................Page H-1
Urgent care ..................................................................................................................................Page H-2
Within California ........................................................................................................................Page H-2
Outside California .....................................................................................................................Page H-2
Seeing a specialist .......................................................................................................................Page H-3
Alternative care ...........................................................................................................................Page H-4
Vision care ....................................................................................................................................Page H-6
Mental health ...............................................................................................................................Page H-6
Health and Wellness Programs
Healthy Lifestyle Rewards Program…………………………………………………………………... Page I-1
blueshieldca.com ..........................................................................................................................Page I-1
LifeReferrals 24/7 ............................................................................................................................Page I-1
Lifepath Decision Guide ...............................................................................................................Page I-2
Disease management programs ................................................................................................Page I-2
Chart Your Course Diabetes Management Program .............................................................PageI-2
Alere® Heart Failure Program ...................................................................................................Page I-2
Reach Your Peak Asthma Management Program ................................................................Page I-3
Shield Your Heart Cardiovascular Risk Reduction Program ..................................................Page I-3
Joint Health Arthritis Self-Care Program ...................................................................................Page I-4
COPD Management Program ..................................................................................................Page I-4
Complex Case Management ......................................................................................................Page I-4
LifeMAPSM (Member Advocacy Program) ..................................................................................Page I-5
Out-of-Area Coverage
Away From Home Care ...............................................................................................................Page J-1
BlueCard Program ........................................................................................................................Page J-1
Prescription Drug Benefits
Drug formulary ..............................................................................................................................Page K-1
Brand vs. generic drugs ...............................................................................................................Page K-1
Pharmacy costs ............................................................................................................................Page K-1
Mail service pharmacy ................................................................................................................Page K-2
Grievance and Appeals Process ................................................................................................Page L-1
Frequently Asked Questions (FAQs) .........................................................................................Page M-1
Sample Forms
Blue Shield member ID card .......................................................................................................Page N-1
BlueCard Worldwide international claim form .........................................................................Page N-2
CalPERS enrollment form HBD-12 ...............................................................................................Page N-5
Confidentiality release form .......................................................................................................Page N-6
PrimeMail Mail Service Pharmacy brochure ............................................................................Page N-8
Express Scripts Mail Service Pharmacy Prescription form ........................................................Page N-9
Grievance form ..........................................................................................................................Page N-10
Guest membership ....................................................................................................................Page N-12
Physician selection ...................................................................................................................Page N-15
Subscriber’s statement of claim form ......................................................................................Page N-16
Medicare Coordinated Care Plan
How to find additional resources ..............................................................................................Page O-1
CalPERS Medicare Coordinated Care Plan Benefits ..............................................................Page O-2
Regional Pricing
Regional Pricing Summary ..........................................................................................................Page P-1
Regional Pricing Map ..................................................................................................................Page P-2
HBO View
Introduction
HBO Resource Guide to Blue Shield Health Plan Benefits
This desktop guide gives you, the Health Benefits Officer (HBO), the information you need to
introduce employees to Blue Shield of California (Blue Shield) and to support existing members.
With easy-to-use tabs and a detailed table of contents, you’ll quickly find the benefits, programs,
plan highlights and resource information you’re seeking.
What you’ll find in the HBO Resource Guide
• Answers to Blue Shield member questions
• Information about the benefits and special programs offered to
Blue Shield members
• Phone numbers, addresses and Web site information
• Open Enrollment information
How to use the HBO Resource Guide to assist your employees
• Look in the table of contents for the subject you’re seeking
• Scroll through the easily marked tabs
• Distribute information to employees. Each page contains one subject only so you can remove,
photocopy and share information with members.
Keeping your HBO Resource Guide current
Please make sure that your guide always has the most up-to-date information about
Blue Shield. When there are changes, we will send you an email to notify you that there are
updates to the “Answer Binder”. You can go to www.blueshieldca.com/calpershbo and select
the “Resource Guide” link and download the updated pages. In order to keep you updated on
the changes, please email calpersam@blueshieldca.com for any contact changes you may
have.
Learn more
If you ever need additional information that you don’t see in this guide, you can go to the
blueshieldca.com/calpershbo or call the HBO Priority Line at (800) 837-4251. We’re always ready
to help.
We appreciate your support in educating your employees about Blue Shield, and we hope this
guide makes it even easier to understand Blue Shield’s value, benefits and programs.
Health Benefits Officer Resource Guide • A-1
Directory
Health Benefits Officer Contact Information
To best serve you in getting timely information and problem resolution, the information in this
section is for the use of Health Benefits Officers only and should not be distributed to members.
Health Benefit Officer Priority Line ............................................................................(800) 837-4251
Contact the HBO priority line when you need assistance with your employees’ Blue Shield
benefits, claims or Personal Physician selection. For all other questions please contact your
Account Manager directly.
Account Management Team
Manager, Account Management*
Ann DeRose …............................................................................................................ (916) 329-4558
Account Manager
Heidi Van Gilse........................................................................................................... (916) 329-4569
(Northern California)
Account Service Representatives*
Susan Vogt………………............................................................................................ (916) 329-4581
(Fresno, Kern, Kings, Los Angeles, Madera, San Luis Obispo,
Santa Barbara, and Ventura Counties)
Rose Allen .................................................................................................................. (916) 329-4554
(Imperial, Orange, Riverside, San Bernardino and San Diego Counties)
Account Management and Health Fair Coordinator
Leyla Hastings………………………………………………………………………………. (916) 329-4560
Communication Specialist
Cynthia Arteaga…………………………………………………………………………… (916) 329-4582
General e-mail Inquiries
Account Management e-mail address.....................................calpersam@blueshieldca.com
HBO Correspondence Address
400 Capitol Mall, Suite 2580
Sacramento, CA 95814
Ordering Blue Shield Collateral
COMAC ............................................................................................. http://calpers.litorders.com/
*See map on page B-3
Health Benefits Officer Resource Guide • B-1
continued from previous page
Member Contact Information
Dedicated CalPERS Blue Shield Member Service line ……….........................................(800) 334-5847
Access+ HMO and EPO benefit information
Guest Membership
Request new member ID card
Select a physician by phone
Collections
Claims
Provider Billing
Other information requests
LifeReferrals 24/7SM ...............................................................................................................1-866 5433728
NurseHelp 24/7 SM.................................................................................................................1-866 543-3728
Healthy Lifestyle Rewards………………………………….……………………….……………(877) 932-3375
Reach Your Peak Asthma Self-Management Program ……......................................... (866) 816-5266
Chart Your Course Diabetes Management Program ....................................................(866) 816-5266
Shield Your Heart Cardiovascular Risk Reduction Program ...........................................(866) 816-5266
COPD Management Program ..........................................................................................(866) 816-5266
Joint Health Arthritis Self-Care Program ...........................................................................(877) 289-4415
Alere® Heart Failure Program ...........................................................................................(877) 289-4415
LifeMAPSM (Member Advocacy Program) .......................................................................(800) 394-3516
BlueCard Worldwide ..............................................................................................(800) 810-BLUE (2583)
Guest Membership ...........................................................................................................(800) 334-5847
Blue Shield Pharmacy Services
(For physician use ONLY, members may give this number
to their Personal Physician, for the physician to provide prior
authorization for the member’s prescription) ..................................................................(800) 535-9481
PrimeMail............................................................................................................................. (866) 346-7200
Discount Vision Program
Eye Care Network Vision Program ....................................................................................(800) 877-6372
Mental Health and Substance Abuse
Mental health services administrator (MHSA),
U.S. Behavioral Health Plan, California (USBHPC) ............................................................(866) 505-3409
Blue Shield E-mail Address for Privacy Issues
Privacy issues e-mail address ..............................................blueshieldca_privacy@blueshieldca.com
Member Correspondence Address
Blue Shield
P.O. Box 272540
Chico, CA 95927-2540
Blue Shield Service Areas
Open Enrollment
Open Enrollment is an important opportunity to introduce your employees to Blue Shield and to
give members information about their current health plan. We strive to make the experience
smooth and successful for you, and informative and enjoyable for your employees.
During Open Enrollment fairs, Blue Shield representatives can be available to answer your
questions, as well as discuss benefits and special wellness programs with members and
prospective members.
Members can pick up helpful information such as Personal Physician selection forms and
pharmacy mail service information and forms. They can also reference the Blue Shield provider
directory and formulary.
Following are a few guidelines for getting the support you need from Blue Shield during Open
Enrollment.
Request that a Blue Shield Representative attend an Open
Enrollment fair
To streamline the process of scheduling a CalPERS Health Fair, CalPERS and Health Plan Partners
have developed an online registration system. You may access this online registration system at
www.healthfairregistration.com By logging on using your Agency Code and ZIP Code, the
Health Benefit Officer can view the health fair master calendar of available health fair dates
and times, select and book a health fair, and alert the health plans simultaneously of their
chosen fair date. Each health plan will contact you to confirm their attendance. Your Agency
Code can be found on your CalPERS billing statement or by calling CalPERS Members Services
at 1-888-CAL-PERS. If your code includes only 4 digits, please enter 000 in the second field (for
example: 1234 000).Once you log in, you will be able to review step-by-step instructions of how
to book your health fair.
HELPFUL HINTS FOR A SUCCESSFUL HEALTH FAIR:
CalPERS and the Health Plan Partners want to help you and your employees have a successful
Open Enrollment. We also want to supply you with the support that you need, but in order to
service the needs of the CalPERS agencies, we ask that you please adhere to these suggested
guidelines:
•
Please reserve your date as soon as possible.
•
Please limit the duration of your health fair to no more than three (3) hours in length.
•
Please publicize the event as much as possible, highlighting the specific hours and health
plan partners that will be available to answer questions. (For your convenience you can
find down loadable email and flyer templates on this page.)
•
Please invite your dental and vision health plan partners and other vendors such as local
health clubs or life insurance providers to increase attendance and promote health.
•
Provide healthy snacks for your employees who attend the health fair.
•
Please try and avoid scheduling your health fair on heavily booked dates.
•
Please schedule your health fair in a room with adequate space whenever possible.
Ordering materials for an Open Enrollment fair
Blue Shield Account Management will send the materials you need for the Open Enrollment fair.
You do not need to request the materials. If you need additional supplies, you can contact your
Account Manager. Or, you can always order them online at: calpers.litorders.com.
Health Benefits Officer Resource Guide • C-1
Great reasons to choose Blue Shield
Not-for-profit health plan
Blue Shield of California is a San Francisco-based, not-for-profit health plan with nearly 70 years
of service to our community.
Blue Shield of California Foundation
Blue Shield of California endows the Blue Shield of California Foundation through annual
contributions supporting the foundation’s work to make health care effective, safe, and
accessible for all Californians, and to end domestic violence.
Competitive monthly rates
®
SM
The Blue Shield Access+ HMO and NetValue
at competitive rates.
HMO plans offer comprehensive health benefits
The doctors and hospitals you trust
The Access+ HMO plan offers one of the largest HMO networks in the state. Or opt for the
NetValue HMO with a smaller network of physicians and medical groups, and pay less.
Self-refer to a specialist
Your Access+ HMO and NetValue HMO plans give you plenty of choice. You can see a specialist
recommended by your Personal Physician, or you can choose to self-refer to a specialist within
your medical group or IPA (Independent Practice Association).* While this self-referral feature
has a slightly higher copayment, the choice is yours.
Dedicated CalPERS Blue Shield Member Services
Your dedicated Member Service representatives are trained on all the features and benefits of
your CalPERS health plan. Call (800) 334-5847, Monday through Friday, 7 a.m. to 7 p.m.
Chiropractic, acupuncture, and massage therapy discounts
Get at least 25% off published fees for chiropractic, acupuncture, and massage therapy from
participating practitioners.**
$200 cash with Healthy Lifestyle Rewards
Healthy Lifestyle Rewards is a confidential, online program that rewards CalPERS Blue Shield
members 18 and older with up to $200 when you participate in the program. It provides valuable
tools to help you get in shape, eat right, reduce stress, or quit smoking – all at no extra charge.
SM
NurseHelp 24/7
SM
and LifeReferrals 24/7
Get round-the-clock access to medical information from a registered nurse by phone or online.
Or talk to master’s-level counselors for support with work and personal issues. All communications
are completely private and available 24 hours a day, seven days a week.
Urgent care away from home
Through the BlueCard® Program, you and your covered family members have access to urgent
care across the country and around the world.
Mail service prescriptions
Use Blue Shield’s mail service pharmacy to fill maintenance medications with stabilized dosages
for the treatment of long-term conditions such as high blood pressure. The mail service benefit
can be used for up to a 90-day supply.
Health Benefits Officer Resource Guide • D-1
What is the difference between Access+ HMO, NetValue
and EPO
Access+ HMO
Blue Shield knows that choice and affordability in a healthcare plan are important to you. Your
Access+ HMO plan offers the same comprehensive benefits as NetValue HMO, but from a wider
network of physicians for a higher monthly rate.
Find out if your doctor is an Access+ HMO provider
To find out if your Personal Physician is an Access+ HMO plan provider, go to
blueshieldca.com/calpers and click on Find a Provider. Or, for personal assistance, you can call
your CalPERS-dedicated Blue Shield Member Services team at (800) 334-5847 from 7 a.m. to 7
p.m., Monday through Friday.
For complete details on your Blue Shield Access+ HMO please refer to your HMO Evidence of
Coverage or visit www.blueshieldca.com/calpers.
NetValue HMO
Blue Shield’s NetValue HMO plan offer you lower monthly rates, yet provides the same
comprehensive Blue Shield benefits, self-referral to specialist, programs, and value-added
services as the Access+ HMO Plan.
CalPERS members enrolled in the NetValue HMO plan will have address to a smaller number of
selected medical groups and affiliated Personal Physicians and specialists than are available in
Blue Shield’s Access+ HMO plan; at a lower monthly rate.
You and all eligible dependents must choose to enroll in the same Blue Shield plan. It is
important to note that except for certain situations, you will not be able to change plans until
the next CalPERS open enrollment period. You can change plans during the plan year under
circumstances for special enrollment specified in the CalPERS Health Program Guide. These
include such circumstances as marriage and new dependents.
Find out if your doctor is a NetValue HMO provider
To find out if your personal physician is a NetValue HMO provider, go to
blueshieldca.com/calpers and click on Find a Provider. Or, for personal assistance, you can call
your CalPERS-dedicated Blue Shield Member Services team at (800) 334-5847, from 7 a.m. to 7
p.m.
Some physicians may practice with more than one medical group/IPA; therefore, in order for
you to continue seeing your current Personal Physician in NetValue HMO plan, you may need to
change medical groups. If you would like to continue care with a specialist you are currently
seeing, be sure to find out if he or she participates in the NetValue HMO plan medical group you
select.
For complete details on your Blue Shield NetValue HMO plan, refer to the addendum to your
NetValue HMO Evidence of Coverage and Disclosure Form or visit
www.blueshieldca.com/calpers.
continued on next page
Health Benefits Officer Resource Guide •E-1
Exclusive Provider Organization (EPO)
Blue Shield's Exclusive Provider Organization (EPO) Basic Plan offers the same comprehensive,
flexible health coverage as the Access+ HMO throughout Sierra, Colusa, and Mendocino
counties. As an EPO plan member, you don't need to select a Personal Physician.
Health Benefits Officer Resource Guide • E-2
CalPERS Blue Shield Benefits: HMO/Net Value* and EPO**
* Available in certain areas. Please refer to Evidence of Coverage
** Colusa, Mendocino and Sierra Counties
Health Benefits Officer Resource Guide • E-3
How to Enroll
Annual Open Enrollment
Please see the “Open Enrollment” section on page C-1 for information regarding Open
Enrollment fairs and materials.
How to enroll – CalPERS ACES
Information about enrollment can be found in the CalPERS Health Program Handbook.
To enroll, employees must complete CalPERS form HBD-12.
How to enroll with Blue Shield
1. Enroll
If an employee is already enrolled with Blue Shield, that employee doesn’t need to do anything
during Open Enrollment to keep the plan and physician he or she chose last year.
If an employee is not yet enrolled with Blue Shield, that employee will need to submit a health
plan enrollment form to his or her employer. Employees can get this form (HBD-12) from their
employer or download it online from CalPERS at www.calpers.ca.gov.
2. Select a Personal Physician
If an employee is enrolling in our Access+ HMOSM or Net Value plan, or wishes to change his or
her Personal Physician, our provider directory is available online at blueshieldca.com. Employees
can click on the Find a Provider tab to search the most current physician,
hospital, mental health provider and alternative care practitioner listings.
Members must tell us who they have selected as their Personal Physician. They can either enter
this information on blueshieldca.com/calpers or call Member Services at (800) 334-5847.
If the member does not select a Personal Physician at the time of enrollment, Blue Shield will
designate a Personal Physician for the member and send notification of the designated Personal
Physician. This designation will remain in effect until the member notifies Blue Shield of his or her
selection of a different Personal Physician.
Members living in Colusa, Mendocino, and Sierra are part of the EPO plan and do not need to
select a Personal Physician. They will have access to providers in our PPO network. They can go
to the Find a Provider section of blueshieldca.com, then click “Find a doctor” and select
“CalPERS EPO.”
3. Register online at blueshieldca.com
Members should be sure to register on blueshieldca.com – their online resource for health and
benefit information 24 hours a day, seven days a week. At our Web site, they will access the tools
and information they need to help them make important decisions about their health.
Health Benefits Officer Resource Guide • F-1
Enrolling dependents
When adding dependents to their health coverage plans, members will need to tell
Blue Shield the names of each dependent’s Personal Physician within three business
days of returning their HBD-12 form. Dependents’ Personal Physicians must be in the Blue Shield
network.
A Personal Physician must be selected for a newborn or child placed for adoption, preferably
prior to birth or adoption, but within 31 days from the date of birth or placement for adoption.
For the first 30 days, the baby must be in same medical group or Independent Practice
Association (IPA) as the mother. For further information, members can refer to their current
Evidence of Coverage (EOC) booklet. Dependants are eligible for coverage up to the age of
23.
Members can provide dependent information in one of three ways. They can:
1. Go online at blueshieldca.com/calpers. Once there, they should select the “search for a
physician” box and click “go.” They will select a Personal Physician for each eligible family
member from the search results. They will then fill in the online form, confirm the information
and click “submit.”
2. Complete a physician selection form, which is included in the Blue Shield enrollment material.
As an HBO, you can order these materials at blueshieldca.com/calpershbo.
3. Call Blue Shield Member Services at (800) 334-5847.
Health Benefits Officer Resource Guide • F-2
Modifications for Existing Members
Changing Personal Physicians
A member may change Personal Physicians by calling Member Services at (800) 334-5847. The
change will be effective the first day of the month following notice of approval by Blue Shield.
Once the Personal Physician change is effective, all care must be provided or arranged by the
new Personal Physician, except for:
• OB/GYN services provided by an obstetrician/gynecologist or a family practice physician
within the same medical group or IPA as the member’s Personal Physician
• Access+ Specialist visits
Please have members refer to their current Evidence of Coverage booklet for additional
information.
Continuation of coverage
COBRA: The COBRA plan will cost an employee 102 percent of their current premium rate. For
example, if the member is currently on an employee-only rate of $315.22, their monthly cost on
COBRA will be $321.52.
To help facilitate an employee’s request for COBRA, HBOs should do the following:
1. Have the employee complete the COBRA HBD-85 form. The form can be downloaded from
the CalPERS Web site at: www.calpers.ca.gov/msspub/pdf/cobraelection.pdf.
2. Update ACES with COBRA information (if HBO has access)
3. Send the completed COBRA HBD-85 form to CalPERS at:
CalPERS Health Benefit Services Division
P.O. Box 942714
Sacramento, CA 94229-2714
4. Send the check for initial dues to:
Blue Shield
Attention: V. Ludovissy
PO Box 769025
Woodland, CA 95776
5. If you are unable to update ACES, send the payment check with the HBD-85 form directly to
CalPERS.
When CalPERS receives the form, it does the following:
1. Processes the COBRA HBD form and updates ACES if needed.
2. Mails the stamped COBRA HBD form to:
Blue Shield of California
EDH - CalPERS Bookkeeping Dept A-2
P.O. Box 629019
El Dorado Hills, CA 95762-9019
Health Benefits Officer Resource Guide • G-1
3. Forwards the employee’s COBRA check to:
Attn. V. Ludovissy
PO Box 769025
Woodland, CA 95776
After the member’s records have been updated to reflect COBRA the member will receive a
COBRA dues notice/billing from Blue Shield, and should pay Blue Shield directly.
Blue Shield currently has two addresses for handling CalPERS COBRA payment:
Members who have a statement mail their payment to:
Cash Receiving
P.O. Box 51827
Los Angeles, CA 90051-6127
Members who do not have a statement mail their payment to:
Attn. V. Ludovissy
PO Box 769025
Woodland, CA 95776
Cal-COBRA: Effective January 1, 2003, any employee who currently has federal COBRA
coverage is eligible for an extension under Cal-COBRA legislation resulting from Assembly Bill
1401. Ninety days prior to their termination of COBRA, they will receive a letter from Blue Shield
advising them of this option. They then have 60 days to notify Blue Shield that they are electing
the extension. The rates will be 110 percent of regular rates, rather than the 102 percent that
COBRA will charge.
The purpose of this law is to offer Cal-COBRA coverage to extend employees’ coverage up to
36 months total coverage, with the two plans (COBRA and Cal-COBRA). If they have 29 months
of federal COBRA, they would have only 7 months of Cal-COBRA available to them. Blue Shield
bills members for Cal-COBRA coverage, similar to COBRA billing.
Blue Shield is responsible for providing potential COBRA enrollees with a 90-day notice
of their COBRA rights. Under Cal-COBRA the COBRA notification must also include
information about CalCOBRA.
If the enrollee elects to apply for coverage under Cal-COBRA he or she may enroll by notifying
Blue Shield’s CalPERS Member Services team at (800) 997-3770. COBRA participants must
contact Blue Shield at least 30 days before their COBRA coverage terminates. Upon notification,
Blue Shield will send an application packet to the CalPERS member.
When switching to Cal-COBRA there will be no changes for members and they will continue to
receive a Cal-COBRA dues notice/billing from Blue Shield.
Blue Shield currently has two addresses for handling CalPERS Cal-COBRA payments as follows:
Members who have a statement mail their payment to:
Blue Shield
Cash Receiving
P.O. Box 51827
Los Angeles, CA 90051-6127
Members who do not have a statement mail their payment to:
Blue Shield
CalCOBRA/PERS
P.O. Box 769022
Woodland, CA 95776-9022
Workers’ compensation
Blue Shield does not provide benefits for any employment-related injury or disease covered by
workers’ compensation law, occupational disease law or similar legislation.
Conversion plan
Within 30 days following the loss of eligibility of CalPERS health coverage or COBRA group
continuation coverage, a member can request an individual conversion policy through his or
her Blue Shield health plan, but the medical benefits and premium costs may differ from the
group coverage. Members can call Individual and Family Plan Member Services at (800) 4312809 to learn about benefits and costs under the conversion plan.
Leave of absence (LOA)
When an employee is taking a leave of absence, CalPERS will notify the employee if he or she
may continue their medical coverage at their own expense. The HBO can update LOA
employment status change, discontinuation and direct pay election through ACES. The HBO
determines that the employee is eligible to change from automatic payroll reduction to Direct
Pay coverage. With Direct Pay, Blue Shield bills the member directly and the employee pays
Blue Shield directly for the full amount of his or her healthcare coverage. When the employee
returns to work, the employment and health enrollment status will not change until the HBO has
updated the employment information with the return-to-pay status. The HBO must also change
the premium payment method to discontinue the direct pay election.
If the HBO is not able to process the transactions associated with the LOA employment status
and direct pay election due to lack of ACES access, then CalPERS will process the transaction. In
this case, an HBD-21 form can be downloaded online at www.calpers.ca.gov.
Send to:
CalPERS Health Benefits Branch
PO Box 942714
Sacramento, Ca. 94229-2714
Obtaining Medical Services
Guidelines for accessing care
These are guidelines that Blue Shield asks its providers to follow. In general, members can
expect to obtain an appointment within these time frames:
Emergency care .....................................................................................................Immediately
Urgent care .........................................................................................................Within 24 hours
Non-urgent care with Personal Physician ........................................Within 14 calendar days
Routine physical exam or well-baby exam .....................................Within 30 calendar days
Specialist referral/consultation (non-urgent) ...................................Within 30 calendar days
General care
When HMO members need preventive care, such as routine checkups and immunizations, or
other non-urgent care, they should call their Personal Physician to make an appointment. The
Personal Physician is responsible for providing primary care and coordinating or arranging for a
referral to other necessary healthcare services.
A female member may arrange for OB/GYN services provided by an obstetrician/gynecologist
or family practice physician who is not her designated Personal Physician without a referral.
However, this doctor must be in the same medical group or IPA as her Personal Physician.
To see which preventive services are covered under their Access+ HMO plan, members should
refer to their Evidence of Coverage booklet.
Getting emergency and urgent care
Please read the following definitions to understand how emergency and urgent care
services are defined for Blue Shield HMO plans.
Emergency care
Emergency care is defined as services provided for an unexpected medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), including a
psychiatric emergency medical situation, such that the absence of immediate medical
attention would reasonably be expected to result in any of the following:
• Placing the member’s health in serious jeopardy
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part
What members should do in an emergency?
If they reasonably believe that an emergency exists, they should call 911 or go to the nearest
hospital. They should contact their Personal Physician as soon as reasonably possible after
receiving emergency care. If they need any follow-up care, they should make sure their
Personal Physician coordinates it.
Health Benefits
Officer Resource Guide • H-1
Coverage levels for emergencies
If a member receives non-authorized services in a situation that Blue Shield determines was not a
situation in which a reasonable person would believe that an emergency condition existed, the
member will be responsible for the costs of those services.
Urgent care
Urgent care is defined as services provided in response to the patient’s need for a prompt
diagnostic work-up and/or treatment of a medical or mental disorder that could become an
emergency if not diagnosed and/or treated in a timely manner and delay is likely to result in
prolonged temporary impairment, unwarranted prolongation of treatment increasing the risk of
treatment by the need of more complex or hazardous treatments, development of chronic
illness or inordinate physical or psychological suffering of the patient.
How to get urgent care
Within their Personal Physician’s service area, members should always call their Personal
Physician before getting treatment for an urgent care situation. Urgent care must be provided or
arranged by their Personal Physician. If they need urgent care or get sick after hours, their
doctor’s office will have someone on call 24 hours a day, seven days a week to help them.
Urgent care within California
When members need urgent care in a part of California that’s outside their Personal Physician’s
service area, they must contact their Personal Physician, who is responsible for providing or
arranging their urgent care. Their Personal Physician has telephone access available 24 hours a
day, seven days a week.
If members are unable to reach their Personal Physician when they need urgent care in another
part of California, they should call Member Services at (800) 334-5847 for help locating an urgent
care provider.
Urgent care outside of California
Through the BlueCross BlueShield Association’s BlueCard® Program, HMO members and their
eligible family members have coverage for urgent care across the country and around the
world. They can locate a BlueCard provider at any time by calling (800) 810-BLUE (2583) or by
visiting our website, blueshieldca.com, click “Find a Provider,” then the link for providers outside
of California. If members are traveling outside the U.S. and territories, they should click the link for
providers outside of the U.S. and follow the search instructions.
Health Benefits Officer Resource Guide • H-2
Follow-up to urgent care obtained outside California
If members receive urgent care through the BlueCard Program, their medically necessary followup care is also covered through the BlueCard Program when they remain temporarily outside of
California.
However, they will need to contact Member Services at (800) 334-5847 to receive authorization
for more than two medically necessary follow-up outpatient visits, for surgical or other
procedures and for inpatient hospital stays. There is a possibility that we may direct them to
obtain these types of follow-up care from their Personal Physician in California.
Seeing a specialist
HMO members may choose a specialist themselves through the Access+ Specialist option. This
option allows them to visit a specialist or primary care physician without a referral. Their copayment is $30 for this office visit. Members need to know that the specialist they choose must
be in their Personal Physician's medical group or IPA and the provider must participate in the
Access+ Specialist program. They can use Find a Provider on blueshieldca.com to find a
specialist in their Personal Physician’s IPA or medical group. The specialist will inform the
member’s Personal Physician of the results of the examination or consultation, and provide any
test results.
An Access+ Specialist visit includes:
• An examination or other consultation provided to the member by a medical group
or IPA plan specialist without referral from their Personal Physician. Note: Except for mental
health and substance abuse visits, the Access+ Specialist must be in the same medical group
or IPA as the member’s Personal Physician.
• Mental health services. Members may arrange for an Access+ Specialist office visit for mental
health and substance abuse services without a referral from the Mental Health Services
Administrator (MHSA), as long as the provider is an MHSA preferred provider.
• Conventional X-rays such as chest X-rays, abdominal flat plates and X-rays of bones to rule out
the possibility of fracture (not including any diagnostic imaging such as CT, MRI or bone
density measurement).
• Laboratory services.
• Diagnostic or treatment procedures that a plan specialist would regularly provide under a
referral from the Personal Physician.
Health Benefits Officer Resource Guide
• H-3
An Access+ Specialist visit does NOT include:
• Any services that are not covered or not medically necessary.
• Services provided by a non-Access+ provider (such as podiatry and physical therapy), except
for the X-ray and laboratory services described above.
• Allergy testing.
• Endoscopic procedures.
• Any diagnostic imaging including CT, MRI or bone density measurement.
• Injectables, chemotherapy or other infusion drugs, other than vaccines and antibiotics.
• Infertility services.
• Emergency services.
• Urgent care services.
• Inpatient services or any services that result in a facility charge, except for X-ray and
laboratory services.
• Services for which the medical group or IPA routinely allows members to self-refer without
authorization from the Personal Physician.
• OB/GYN services by an obstetrician/gynecologist or family practice physician within the same
medical group/IPA as the Personal Physician.
• Internet-based consultations with specialists.
• Psychological testing and written evaluation.
Alternative care
Our Mylifepath Alternative Health Services Discount Program offers discounts for:
Acupuncture
Receive at least 25 percent off:
• Examinations
• Acupuncture or electro-acupuncture
• Adjunctive therapeutic procedures or modalities
• Other related acupuncture services
Note: Does not include herbs
Chiropractic
• Examinations
• Manipulative treatment
• Adjunctive therapeutic procedures or modalities
• Chiropractic appliances
• Other related chiropractic services
Massage therapy
• Swedish massage
• Deep muscle and deep tissue massage
• Trigger point therapy
• Shiatsu and acupressure
• Reflexology
• Sports massage
To receive these discounts, members need to:
• Select a practitioner in the Mylifepath Alternative Health Services Discount Program.
• Call the practitioner or facility to make an appointment.
• Present their Blue Shield member ID card at the time of their appointment. They must show
their card to receive the discount.
Members can go to blueshieldca.com, click and search in the Find a Provider section to find a
Mylifepath Alternative care provider in their area.
Please note: The Mylifepath Alternative Health Services Discount Program is an exclusive offer to Blue Shield members,
made available through an arrangement with American Specialty Health Networks (ASH Networks) and is not a covered
service of any Blue Shield health plan. ASH Networks credentials and manages the program’s practitioners. None of the
terms and conditions of Blue Shield health plans apply. Blue Shield and ASH Networks do not review the program’s
practitioner services and products for medical necessity or efficacy and make no representations, claims or guarantees
regarding their services or products. Members who use the discount program are responsible for the payment of services
provided by participating network practitioners, including payment for cancelled or missed appointments. Members
who are not satisfied with services received from the program’s practitioners may use the Blue Shield grievance process.
Blue Shield reserves the right to terminate this program without notice.
Vision care
Eye refraction to determine need for corrective lenses is $0 per visit and must be referred by a
primary care physician (frames and lenses not covered). However, this service is limited to one
visit per calendar year for members.
In addition, Blue Shield members benefit from the Eye Care Network Discount Vision Program
(ECN), which offers 20 percent discounts on eye exams, glasses, contacts and more, including:
• Routine eye examinations
• Frames and lenses
• Contact lenses
• Photochromatic lenses
• Tints and coatings
This program is not a covered service of the member’s health plan, but an additional offer of
savings to Blue Shield members.
To receive discounts from providers found in the ECN directory, members simply present their
Blue Shield member ID card when purchasing the products or services listed above. They pay
participating providers’ published fees, less the 20 percent discount. Members are responsible for
all incurred charges, so there is no need to file a claim.
Members can locate an ECN provider near them using the Find a Provider search feature on
blueshieldca.com.
ECN does not apply to disposable or replaceable contact lenses, eyeglass frame repairs,
promotional eye care offers, medical or surgical eye treatments or any other services or supplies
not specifically covered under this program.
Please note: The Eye Care Network Vision Program is a value-added feature exclusively for Blue Shield members who
reside in California and is not a covered benefit of Blue Shield health plans. None of the terms
or conditions of Blue Shield’s health plans apply. Disposable and replaceable contact lenses, eyeglass frame repairs,
promotional eye care offers, medical and surgical eye treatment and any services not specifically included in this
program are excluded from the Eye Care Network Vision Program.
Mental health
Blue Shield has contracted with a mental health services administrator (MHSA), U.S. Behavioral
Health Plan, California, to deliver mental health and substance abuse services to our members
through a unique network of mental health preferred providers. All non-emergency mental
health and substance abuse services, except for Access+ Specialist visits, must be arranged
through the MHSA. Members do not need to arrange for mental health and substance abuse
services through their Personal Physician.
A MHSA preferred provider must provide all mental health and substance abuse services,
except for emergency or urgent services. MHSA preferred providers are listed in the Find a
Provider section of blueshieldca.com and in the Blue Shield Behavioral Health Provider Directory.
Members may contact the MHSA directly for more information and to select a MHSA preferred
provider by calling (866) 505-3409. For details about these benefits, members should consult their
Evidence of Coverage booklet.
Healthy Lifestyle Rewards Program
Healthy Lifestyle Rewards Program is a confidential, online program that rewards CalPERS Blue
shield members 18 and older with up to $200 when you participate in the program. It provides
valuable tools to help you get in shape, eat right, reduce stress, or quit smoking – all at no extra
charge.
blueshieldca.com
blueshieldca.com is Blue Shield’s online health and wellness Web site. To take full advantage of
the site features, members need to register at the site. When they register, they will find answers
to most of their benefit and health and wellness program questions.
• Plan and benefit information: The password protected My Health Plan section contains CalPERS
benefit information, frequently asked questions, downloadable forms, Member Services
contacts and more.
• Health and wellness tools and news: Our online health and wellness resources provide
members with interactive tools, up-to-date health information from the nationally recognized
Mayo Clinic, health news from Reuters Health Information, plus information on Blue Shield
member programs to help them better manage
their health.
• Pharmacy and prescription coverage information: Members can search the Pharmacy section
for a list of formulary drugs, find generic alternatives, check for drug interactions, find out
information about their medications, refill maintenance prescriptions by mail and locate a
participating pharmacy. They can also submit questions about prescription drugs or over-thecounter medications, herbal products or dietary supplements securely online to a clinical
pharmacist at the University of California, San Francisco, School of Pharmacy, and receive a
personal, confidential answer within two business days.
Note: Personal health information is confidential and will not be shared.
LifeRefferals 24/7
This program helps members better manage the demands of everyday life. They can receive
information, referrals, resources and support 24 hours a day, seven days a week – at no extra
charge. All communications are completely confidential.
Here are some additional details about this helpful program:
• Counseling service: Members can access experienced counselors for a range of work and
personal issues and work-life specialists for when they need help balancing work and life.
Members can call for essential healthcare, financial, legal and other resources
1-866-LIFEPATH (543-3728). TDD 1-866-216-9926. Or they can go to the “Health & Wellness”
section of blueshieldca.com/calpers and click the “lifepath resources” link.
• Nurseline: Members can speak with a registered nurse over the phone toll-free for medical
information they can trust. These nurses are also available anytime by calling 1-866-LIFEPATH
(543-3728), 1-TDD 866-216-9926.
• Nurse Chat: Members can have a secure, confidential online chat with a registered nurse.
They simply log on to blueshieldca.com and go to the “Health & Wellness” section and click
the “lifepath advisers” link to use these online services and to get more information privately.
Health Benefits Officer Resource Guide •I-1
Lifepath Decision Guide
Members will find relevant information about hospitals, treatment options and medications that
might be appropriate for their specific situation. Through blueshieldca.com, the Lifepath
Decision GuideSM includes:
• Hospital Comparison Tool: Members can compare hospitals’ quality and cost for their
condition or procedure.
• Treatment Options Tool: This tool helps members find potential treatment options for their
condition or diagnosis
• Drug Database and Formulary: Members can access drug copayment information and look
up which drugs are available as generics, to better manage out-of-pocket prescription
expenses and learn which drugs are on Blue Shield's formulary.
• Drug Interactions: Members can check for potential side effects caused by the
medications they take.
Disease management programs
We’ve designed a suite of health management programs to help members feel better and
manage their conditions. When they participate in our programs, they get practical resources
and support – at no additional charge. Participation will not affect their benefits or their access
to providers in any way, and all information is kept confidential.
Chart Your Course Diabetes Management Program
Members with diabetes can participate in our diabetes management program. If they choose
to participate they will receive a workbook that contains information and tools about the
diabetes management program. Additionally each participating member will receive a
welcome call by a program nurse to review their current health status and identify educational
topics that may be useful.
Participation will not affect their benefits or their access to providers in any way, and all
information is kept confidential.
For more information, members can contact:
(866) 816-5266
Hearing or speech-impaired members should call TDD (866) 782-7237
Alere Heart Failure Program
Blue Shield has partnered with Alere® Medical Inc. to offer qualified members diagnosed with
severe heart failure a program to help monitor their condition. If they have had a recent
hospitalization or ER visit due to heart failure they will receive an information packet and a
phone call from an Alere representative. If a member’s status seems to have worsened (e.g., if
the member is experiencing increased symptoms or rapid weight gain), an Alere nurse will notify
the member’s physician to so that clinical follow-up can occur immediately if necessary.
Health Benefits Officer Resource Guide • I-2
information will be kept confidential.
For more information about the Alere Heart Failure Program, members can contact:
(877) 289-4415
Hearing or speech impaired members should call:
(800) 794-1099
Reach Your Peak Asthma Management Program
Reach Your Peak helps members create a personal action plan to manage asthma symptoms.
This program is designed to help members who have daily or nightly symptoms more than once
a week. They’ll learn to understand how best to respond to their symptoms and form a strong
partnership with their healthcare provider. If they choose to participate they will receive a
workbook that contains information and tools about the asthma management program.
Additionally each participating member will receive a welcome call by a program nurse to
review their current health status and identify educational topics that may be useful.
For more information about the Reach Your Peak asthma program members can contact:
(866) 816-5266
Hearing or speech impaired members should call TDD:
(866) 782-7237
Shield Your Heart Cardiovascular Risk Reduction Program
Making necessary lifestyle changes to manage cardiovascular disease can be very difficult.
Designed for members who have had a heart attack, bypass surgery or angioplasty, Shield Your
HeartSM can help reduce cardiovascular risk and help prevent future heart problems. If they
choose to participate they will receive a workbook that contains information and tools about
the asthma management with cardiovascular risk reduction program. Additionally each
participating member will receive a welcome call by a program nurse to review their current
health status and identify educational topics that may be useful.
Participation will not affect members’ benefits or their access to providers in any way,
and all information is kept confidential.
For additional information about the Shield Your Heart Cardiovascular Risk Reduction Program,
members can contact:
(866) 816-5266
Joint Health Arthritis Self-Care Program
The Joint Health Arthritis Self-Care Program is an education program for adult members with
arthritis. The program was developed in collaboration with the Arthritis Foundation.
Joint Health helps members manage their arthritis by providing information about arthritis and
treatment and by encouraging members to practice self-care skills to stay active, increase their
sense of control and enhance their quality of life.
Participation will not affect members’ benefits or their access to providers in any way,
and all information is kept confidential.
For additional information about the Joint Health arthritis program members can contact:
(877) 289-4415
Chronic Obstructive Pulmonary Disease (COPD) Management Program
Members with Chronic Obstructive Pulmonary Disease (COPD) can participate in the COPD selfmanagement program. If they choose to participate they will receive a workbook that contains
information and tools about the COPD management program. Additionally each participating
member will receive a welcome call by a program nurse to review their current health status
and identify educational topics that may useful.
For additional information about the COPD program, members can contact:
(866) 816-5266
Complex Case Management
Blue Shield, in collaboration with ParadigmHealth, manages care for some CalPERS members
with complex medical conditions. These patients have progressive and/or life-threatening
illnesses, suffer from multiple comorbidities, have numerous care providers, and require more
intensive interventions and coordination than provided by traditional case management or
disease management programs. The program is an intensive intervention typically lasting four to
six months.
ParadigmHealth provides its clinical team, comprised solely of doctors and nurses, with key tools
to enable them to manage these patients successfully
• Time – Low caseloads, approximately 20 to 22 patients per nurse, give nurses time to attend to
the numerous challenges these patients face. All patients receive a home visit from their
personal, community-based registered nurse.
• Training – All clinicians are trained in palliative care and end-of-life issues.
• Systematic approach – Nurses create a care plan organized around seven Care Domains
(Knowledge and Choice, Treatment Plan, Family and Living Environment, Pain and Symptom
Management, Terminal Care Planning, Provider Support and Benefit Plan Management). This
helps structure conversations with patients and their physicians to help ensure a
comprehensive approach to the patient's care needs.
The Blue Shield program goes beyond helping patients manage their benefits and navigate the
medical system; it provides a full range of personalized services, such as pain and symptom
management, early crisis management, psychosocial and spiritual support and access to
community resources. By focusing on the patient’s needs, the program enhances the
relationship between the patient, family and doctor.
LifeMAPSM (Member Advocacy Program)
This program is available to members facing certain types of surgical procedures. LifeMAP is a
program that gives patients personal support from registered nurses to help them prepare for
and recover from surgical procedures.
Before surgery, members get a “recovery map” that provides useful information specific to each
procedure, including information about pre-operative testing and preparation, expected postoperative recovery milestones and the return to work. A registered nurse answers general
questions about the planned surgery and recovery, helping to identify and coordinate any
discharge needs.
Following discharge, the care manager contacts the member to check on his or her recovery,
confirming that discharge needs are met, prescriptions are filled, instructions are understood,
pain is controlled and follow-up appointments are scheduled.
Participation will not effect members’ benefits or their access to providers in any way, and all
For more information about the LifeMAP program members can contact:
(800) 394-3516
Out-of-Area Coverage
®
Away From Home Care
Blue Shield offers members who are long-term travelers, students and families living apart, Away
From Home Care (AFHC), previously referred to as Guest Membership. AFHC offers full HMO
benefits with a member’s ID card. Their eligibility is applicable to their spouse and dependents
who are away from home for at least 90 days, or to the member when they are away form
home for at least 90 days but not more than 180 days. There is no additional charge to the
member.
AFHC also offers a special short-term service, which is available to members, if they require
specific follow-up treatment. This option is particularly beneficial for members who will be out-ofstate on a short-term basis but require special treatment.
To coordinate AFHC members should call Blue Shield CalPERS Member Services at (800) 3345847.
BlueCard Program
BlueCard® provides access assistance for member’s emergency care needs anywhere in the
world. However, they are not required to use the BlueCard program or BlueCard Worldwide
Network for emergency care. If they have an emergency, they should seek care at the nearest
medical facility.
To identify hospitals, which participate in the BlueCard Program, members should call:
(800) 810-BLUE (2583) or they can use “Find a Provider” on blueshieldca.com to search for
providers outside of California before traveling. Or in an emergency they can call collect from a
foreign country to (804) 673-1177, 24 hours a day, seven days a week.
Hospitals participating in the BlueCard program will bill Blue Shield – not the member – for their
covered inpatient expenses. However, they may be asked to pay their copayment or
deductible and will need to pay for services such as physician visits or outpatient care while
traveling internationally. Members should be sure to get an itemized bill for these services so that
Blue Shield can process their claim.
Members can reference their Blue Shield Evidence of Coverage and Disclosure booklet for
complete details regarding the BlueCard Program, the BlueCard Worldwide Network and their
appropriate copayment for out-of-area urgent care.
Member’s who would like to know more about BlueCard program details, should contact the
dedicated Blue Shield CalPERS Member Services at (800) 334-5847 before they travel. We’ll send
them more information.
Health Benefits Officer Resource Guide • J-1
Drug Formulary
The Blue Shield drug formulary is a comprehensive list of preferred drugs maintained by our
Pharmacy and Therapeutics Committee for use under the Blue Shield Outpatient Prescription
Drug Program, which is designed to assist physicians in prescribing drugs that are medically
necessary and cost effective. The formulary is updated quarterly. If not otherwise excluded, the
formulary includes all generic drugs.
Members can review the most updated drug formulary online at blueshieldca.com by clicking
on “Pharmacy” on the top navigation bar. From the menu, they can select Drug Database &
Formulary. From there, they can search by a specific drug name, medical condition or drug
class. Or, they can download the most current formulary from the navigation bar on the righthand side. Members can also obtain a printed copy of the Blue Shield Drug Formulary by calling
Member Services at (800) 334-5847.
A non-formulary drug is any medication that is not listed in the drug formulary. CalPERS’ benefits
provide coverage for non-formulary drugs at a higher non-formulary copayment. Some
formulary and non-formulary medications require prior authorization for medical necessity.
Brand vs. generic drugs
The Food and Drug Administration (FDA) has deemed that generic drugs are therapeutically
equivalent to the correlated brand-name drug. Generic drugs must contain the same active
ingredients in the same amounts as their brand-name counterparts. Additionally, the same
rigorous FDA quality and safety reviews apply to generic drugs as they do to brand-name drugs.
Generic drugs must also cost less than the brand-name drug. Since they cost less, generic drugs
help lower members’ healthcare expenses. Under the Blue Shield Outpatient Prescription Drug
Benefit, members pay a lower copayment if they choose generic drugs over brand-name
medications.
When appropriate, using generic drugs is one way members can play an active role in helping
control the overall costs of health care. Furthermore, copayments are less for generic products,
so using generic drugs can help members maximize the value of prescription drug benefits.
Members should talk to their doctor about generic alternatives that would be right for them.
Pharmacy costs
Pharmacy costs are listed in the Benefit Summary on pages E-1, O-3.
Health Benefits Officer Resource Guide • K-1
PrimeMail Mail Service Pharmacy
Members have the option of obtaining up to a 90-day supply per prescription for covered
maintenance drugs through the mail service pharmacy, PrimeMail. To have PrimeMail fill
prescriptions, members may use the special order forms available from you (the Health Care
Benefits Officer), from Blue Shield Member Services or online.
Prescription refills are available online by visiting blueshieldca.com, clicking “Pharmacy,” then
clicking “Participating Pharmacies,” and then “mail-service prescriptions.” Members will need to
mail a new prescription for a 90-day quantity with refills to PrimeMail using the procedure
outlined in the mail service brochure, obtained by calling PrimeMail at 866.346.7200
Hearing Impaired TTY/TDD 866.346.7197, Fax Refills 877.774.6360
Members should allow up to 14 days to receive mail service prescriptions. Once the prescription
is received by PrimeMail, it normally takes one to two days to be filled and mailed if there are no
questions. Some situations that can delay a prescription from being filled are an incomplete or
illegible prescription, manufacturer backorders and drugs that require prior authorization by Blue
Shield.
If prior authorization is required, the member’s physician must request a review by Blue Shield
Pharmacy Services at (800) 535-9481. Blue Shield Pharmacy Services obtains clinical information
from the doctor and, based on the information provided, makes a decision regarding coverage
of the medication.
Health Benefits
Officer Resource Guide • K-2

Resource Guide, Part 1

Transcription

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