CALL ¾ THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a participating pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-235-8631 or write to us at Blue Cross of California, P.O. Box 60007, Los Angeles, CA. 90060-0007. You may also request replacement cards through our Website at www.bluecrossca.com.

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/or coinsurance, and you will not have to file claims. For treatment of a mental health or substance abuse condition you may request an authorized referral to a non-Plan provider. See Mental Health and Substance Abuse Benefits (Section 5e) for details.

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We publish a directory of Planproviders. You can get a directory which lists all medical groups, IPAs, and the primary care physicians and hospitals that are affiliated with each medical group or IPA. You may call our Customer Service number or you may write to us and ask us to send you a directory. You may also search for a Plan provider using the "Provider Finder" function on our Website at www.bluecrossca.com.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our Website.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. Your primary care physician will be the first doctor you see for all your health care needs. If you need special kinds of care, this doctor will refer you to other kinds of health care providers. This decision is important since your primary care physician provides or arranges for most of your health care. Your primary care physician will be part of a Blue Cross HMO contracting medical group. There are two types of Blue Cross HMO medical groups:

Your primary care physician can be a general or family practitioner, internist or pediatrician. Certain specialists we may approve may also be designated primary care physician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Your doctor may refer you to another physician if you need special care.Your primarycare physician must approve all the care you get except when you have an emergency or need urgent care.

Your doctor's medical group has to agree that the service or care you will be getting from the other health care provider is medically necessary. Otherwise it won't be covered.

• You will need to make the appointment at the other doctor's office.

• Your primary care physician will give you a referral form to take with you to your appointment. This form gives you the approval to get this care. If you don't get this form, ask for it or talk to your Blue Cross HMO coordinator.

• You may have to pay a copayment. You shouldn't get a bill, unless it is for a copayment, for this service. If you do, send it to your Blue Cross HMO coordinator at your primary medical group right away. The medical group will see that the bill is paid. If you need additional help you can call our customer service department.

  Standing Referrals. If you have a condition or disease that:

• Requires continuing care from a specialist; or is

• Life-threatening;

• Degenerative; or

• Disabling;

  your primary care physician may give you a standing referral to a specialist or specialty care center. The referral will be made if your primary care physician, in consultation with you, and a specialist or specialty care center, if any, determine that continuing specialized care is medically necessary for your condition or disease.

  If it is determined that you need a standing referral for your condition or disease, a treatment plan will be set up for you. The treatment plan:

• Will describe the specialized care you will receive;

• May limit the number of visits to the specialist; or

• May limit the period of time that visits may be made to the specialist.

  If a standing referral is authorized, your primary care physician will determine which specialist or specialty care center to send you to in the following order:

• First, a Blue Cross HMO contracting specialist or specialty care center which is associated with your medical group;

• Second, any Blue Cross HMO contracting specialist or specialty care center; and

• Last, any specialist or specialty care center;

  that has the expertise to provide the care you need for your condition or disease.

  After the referral is made, the specialist or specialty care center will be authorized to provide you health care services that are within the specialist's area of expertise and training in the same manner as your primary care physician, subject to the terms of the treatment plan.

  Remember: We only pay for the number of visits and the type of special care that your primary care physician approves. Call your physician if you need more care. If your care isn't approved ahead of time, you will have to pay for it (except for emergencies or urgent care.)

  Ready Access. There are two ways you may get special care without getting an approval from your medical group. These two ways are the "Direct Access" and "Speedy Referral" programs. Not all medical groups take part in the Ready Access program. See your Blue Cross HMO Directory for those that do.

  Direct Access. You may be able to get some special care without an approval from your primary care physician. We have a program called "Direct Access", which lets you get special care, without an approval from your primary care physician for:

• Allergy

• Dermatology

• Ear/Nose/Throat

  Ask your Blue Cross HMO coordinator if your medical group takes part in the "Direct Access" program. If your medical group participates in the Direct Access program, you must still get your care from a physician who works with your medical group. The Blue Cross HMO coordinator will give you a list of those doctors.

  Speedy Referral. If you need special care, your primary care physician may be able to refer you for it without getting an approval from your medical group first. The types of special care you can get through Speedy Referral depend on your medical group.

  If You Are A Woman

  You can get OB-GYN services from a doctor who specializes in caring for women (OB-GYN) or family practice doctor who does OB-GYN and works with your medical group.

• You can get these services without an approval from your primary care physician.

• Ask your Blue Cross HMO coordinator for the list of OB-GYN health care providers you must choose from.

  When You Want A Second Opinion

  Your medical group is responsible for arranging second opinions and specialty care with health care providers who are part of or who are affiliated with your Blue Cross HMO medical group. Working with your medical group supports and improves the coordination and quality of your medical care.

  If your primary care physician referred you to a specialist (called a "group" specialist) and you want a second opinion, you have the right to a second opinion by an appropriately qualified health care professional who is part of the Blue Cross HMO provider network. If there is no appropriately qualified health care professional in the network, we will authorize a second opinion by another appropriately qualified health care professional, taking into account your ability to travel.

  Reasons for asking for a second opinion include, but are not limited to:

• Questions about whether recommended surgical procedures are reasonable or necessary.

• Questions about the diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment, including but not limited to a serious chronic condition.

• The clinical indications are not clear or are complex and confusing.

• A diagnosis is in doubt because of test results that do not agree.

• The first doctor is unable to diagnose the condition.

• The treatment plan in progress is not improving your medical condition within an appropriate period of time.

• You have tried to follow the treatment plan or you have talked with the specialist about serious concerns you have about your diagnosis or plan of care.

  To ask for a second opinion about recommendations by your primary care physician, call your primary care physician or your Blue Cross HMO coordinator at your medical group.

  To ask for a second opinion from a specialist outside your medical group, please call us at 800-235-8631. The customer service representative will verify your Blue Cross HMO membership, get preliminary information, and give your request to an RN case manager.

  A decision is made within five business days from when we get the information necessary to make a decision. Decisions on urgent requests are made within a time frame appropriate to your medical condition and no later than the next business day.

  When approved, your case manager helps you with selecting a Blue Cross HMO specialist within a reasonable travel distance and makes arrangements for your appointment at a time convenient for you and appropriate to your medical condition. If your medical condition is serious, your appointment will be scheduled within no more than seventy-two (72) hours. Your case manager will work with you and your medical group to make sure the specialist has your medical records before your appointment. Except for your usual co-payment, we cover the specialist's fee.

  An approval letter is sent to you and the specialist. The letter includes the services approved and the date of your scheduled appointment. It also includes a toll free number to call your case manager if you have questions or need additional help. Approval is for the second opinion consultation only. It does not include any other services such as lab, x-ray, or treatment by the specialist. You and your primary care physician will get a copy of the specialist's report, which includes any recommended diagnostic testing or procedures. When you get the report, you and your primary care physician or group specialist should work together to determine your treatment options and develop a treatment plan. Your medical group must authorize all follow-up care.

  Only our Medical Director may decide when we will not cover the fees for a specialist you choose. This may happen when you choose a specialist who is not part of the Blue Cross HMO network and the same kind of specialist is available in the network. If your request is not approved, the letter we send you will include the names of the specialists that can be approved.

  You may appeal a disapproval decision by following our complaint process. Procedures for filing a complaint are described later in this booklet under Section 8 and in your denial letter.

  If you have questions or need more information about this program, please contact your Blue Cross HMO coordinator at your medical group or call us at 800-235-8631.

  Here are other things you should know about specialty care:

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

• If you have a chronic or disabling condition and lose access to your specialist because we:

  -- terminate our contract with your specialist for other than cause; or

  -- drop out of the Federal Employees Health Benefits (FEHB) Program and

  you enroll in another FEHB Plan; or

  -- reduce our service area and you enroll in another FEHB Plan, you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or if we drop out of the Program, contact your new plan.

  If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

There may be a time when your primary care physician says you need to go to the hospital. If it is not an emergency, the medical group will look into whether or not it is medically necessary. If the medical group approves your hospital stay, you will need to go to a hospital that works with your medical group. The same is true for admissions to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-235-8631. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• You are discharged, not merely moved to an alternative care center; or

• The day your benefits from your former plan run out; or

• The 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

Circumstances beyond our control

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.

Deductible

This Plan does not have a deductible.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for infertility services.

Your catastrophic protection out-of-pocket maximum

After your copayments total $1,000 for one family member or $3,000 for three or more family members in any calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for these services: