member handbook

blueshieldca.com/bscbluegroove

With Basic Groove, you can see any provider in our Basic Groove provider network or receive service from a non-network provider for a higher cost.*Of course we want you to take advantage of the lower costs and rewards available through Main Groove, but if you choose Basic Groove, you’ll still get comprehensive coverage, along with the ability to see any provider in our Basic Groove PPO network. But be aware that this option will result in substantially higher out-of-pocket costs than Main Groove.

For information about the coverage and specific benefits of Basic Groove, please refer to the Evidence of Coverage and Disclosure Form (EOC&D) booklet. You can also call your dedicated Blue Groove Member Services team at (800) 443-5005 or (800) 218-8601 (for Lodi employees).

* Sutter Health providers are not included in the Blue Groove provider network (Main, Basic, and Care+ Grooves).

SELECtinG YOur DOCtOr Your Basic Groove PPO plan gives you the option to go to a Basic Groove PPO network or non-network doctor or hospital or other provider each time you access care.*

HOW tO LOCatE a BaSiC GrOOvE nEtWOrk PrOviDEr You will typically pay the lowest amount for your plan when you access Basic Groove PPO network providers. You can find a Basic Groove PPO network physician 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 enter a ZiP code and the doctor’s last name or specialty. if you don’t have access to the internet, contact Blue Groove Member Services for help finding a network provider.

CHOOSinG a nOn-nEtWOrk PrOviDEr When you decide to go to a non-network provider, you’ll be responsible for paying a percentage of the provider charges, as well as charges above Blue Shield’s allowable amount. Your copayments and deductibles may be higher, and your calendar-year copayment maximum is set at the highest level for your PPO plan. You’ll also need to file a claim with Blue Shield when you visit a non-network provider. if you need a claim form or have coverage questions about a bill presented to you by a non-network provider, call Member Services.

GEnEraL CarE

You must meet your deductible before Blue Shield pays its share of the cost for most covered services – please refer to the EOC&D to see which covered services are subject to the deductible. after any applicable deductible requirement is met, you only pay the copayment or copayment percentage amount listed in the EOC&D for each covered service.

You will pay nothing for your preventive health benefits from a Basic Groove network provider. For office visits that don’t involve preventive care, there is a copayment for seeing Basic Groove network providers. Please note: Your annual routine physical exam, and annual gynecological exam for women, are not subject to the deductible requirement. For an office visit with a non-network provider, your copayment is a percentage of Blue Shield’s allowable amount for services received. You will also be responsible for all charges above the allowable amount. For an explanation of copayments, deductibles, and allowable amounts, please refer to the EOC&D booklet.

* Sutter Health providers are not included in the Blue Groove provider network (Main, Basic, and Care+ Grooves).

SPECiaLtY CarE

to keep your medical costs down, it’s wise to go to a specialist who is in our Basic Groove PPO network. For an office visit with a non-network provider, your copayment is a percentage of Blue Shield’s allowable amount for services received. You will also be responsible for all charges above the allowable amount.

HOSPitaL CarE

if you need to be hospitalized, you will receive the highest level of benefits when you choose a Basic Groove network hospital, because your copayment is lower than if you use a non-network hospital. if you are admitted to a non-network hospital, your copayment will be a percentage of Blue Shield’s allowable amount for hospital services, and you will also be responsible for charges above the allowable amount. For more information about deductible requirements, copayments, and allowable amounts for hospital services, refer to the EOC&D booklet.

Whenever you are admitted to the hospital, you or your doctor must notify Blue Shield within 24 hours or by the end of the first business day following emergency admissions, or as soon as it is reasonably possible to do so. For scheduled hospitalization, failure to notify Blue Shield in advance will result in your being charged a Benefit Management Program fee. if you access care through the BlueCard Program out-of-state, your inpatient hospital service benefits are the same as when you go to a Basic Groove network hospital here in California. if you have any questions about out-of-state or foreign claims, call Member Services.

ManaGE YOur HEaLtH anD BEnEFitS OnLinEto access important benefits information, go to blueshieldca.com/bscbluegroove, click on your Blue Groove area, then Member Login. register or log in, then select My Health Plan.

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 email claim alerts.

Contact us – Find phone numbers, addresses, or send email to a Blue Groove Member Services representative.

COvEraGE FOr nEWBOrnSYour 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) 322-7348. Once you complete the enrollment, your newborn will automatically be enrolled in Main Groove. if you wish to have your newborn covered under Basic Groove, you must contact Blue Shield Member Services at (800) 443-5005 or (800) 218-8601 (for Lodi employees) within 90 days from your newborn’s date of birth to request Basic Groove for your newborn.

retail pharmacy

Participating pharmacies only

You must meet a separate $150 deductible per member before benefits are paid for brand-name drugs.

$10/generic$40/brand-name formulary

$55/non-formulary

Contraceptive drugs & devices $0 per prescription

Mail order pharmacy

For maintenance drugs, up to 90-day supply You must meet a $150 deductible per member before benefits are paid for brand-name drugs.

$20/generic$80/brand-name formulary

$110/non-formularyParticipating pharmacies only

Contraceptive drugs & devices $0 per prescription

Specialty drugs

From a participating specialty pharmacy only 20% up to $100 copayment maximum per prescription

HiGHLiGHtS OF YOur BEnEFitSHere are key benefits and features of Basic Groove

network providers non-network providersAnnual deductible $1,500 per member

Maximum calendar-year copayment $7,000 per member $10,000 per member

Choosing a doctor

Your Basic Groove PPO gives you the option to go to a Basic Groove network or non-network doctor or hospital each time you access care.

network providers are those who are in our Basic Groove PPO network, while non-network providers are not a part of our Basic Groove PPO network.

Preventive care no charge (deductible waived) not covered

Emergency room $100 per visit + 30% (deductible waived) $100 per visit + 30% (deductible waived)

Laboratory and X-rays (diagnostic testing) $45 per visit 50%

Physician or authorized specialist office visits $45 per visit (deductible waived) 50%

Hospitalization services 30% 50%

Pregnancy and maternity (prenatal and postnatal professional physician services; for all necessary inpatient hospital services, see “Hospitalization services”)

30% 50%

Family planning care• Counseling and consulting • Insertion or removal of IUD• IUD

no charge not covered

Durable medical equipment 50% 50%

MOrE inFOrMatiOn aBOut YOur PHarMaCY BEnEFitSCheck the Basic Groove formulary

it’s easy to access the Basic Groove Drug Formulary to see if your medication is in our list of preferred prescription drugs. Go to blueshieldca.com/bscbluegroove, click on your Blue Groove area, then Member Login. register or log in, then 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 PrimeMail new Order form. You can download the PrimeMail new Order form by logging in to blueshieldca.com/bscbluegroove, clicking on Pharmacy, and then Mail-Service Pharmacy. Or, you can call PrimeMail at (866) 346-7200 to request a form. after you send your order form and prescription to PrimeMail, you can order refills online by going to www.MyPrimeMail.com.

EXtra SErviCES anD SuPPOrtWith Basic Groove, you get a wealth of extra resources to help you manage your health and make more informed healthcare decisions.

NurseHelp 24/7SM − 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) 304-0504. that number also appears on your Basic 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 email 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

SPECiaLiZED HEaLtH ManaGEMEnt PrOGraMS

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.

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 text4babySM* 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) 371-1511.

Chronic condition management programs

Your Basic 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) 954-4567.

Note: if you or someone in your family has a chronic condition, be sure to read the information about Care+ Groove below.* 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.

GEttinG CarE aWaY FrOM HOME

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 one of your enrolled dependents has one of these conditions, call Blue Groove Member Services to find out more about how to qualify to enroll in Care+ Groove.

Please note: to remain in Care+ Groove, you’ll need to follow the care plan that you, your Personal Physician, and your care team develop together. if you don’t comply with your care plan, you will be moved to the Blue Groove in which you originally enrolled at open enrollment. also note that, unlike Main Groove, there is no PPO network access for Care+ Groove due to Care+ Groove’s specialized team approach.

a Care+ Groove member who is reassigned to another Blue Groove due to noncompliance will not be eligible for enrollment in Care+ Groove until the next plan year.

 

nOtiCE On tHE avaiLaBiLitY OF LanGuaGE aSSiStanCE SErviCES tO aCCOMPanY vitaL DOCuMEntS iSSuED in EnGLiSH

WE’rE HErE tO HELPif 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) 443-5005 or (800) 218-8601 (for Lodi employees)

BlueCard Program .....................................................................................................................(800) 810-BLuE

NurseHelp 24/7 .......................................................................................................................... (877) 304-0504

LifeReferrals 24/7....................................................................................................................... (800) 985-2405

Blue Shield of California Privacy Office ................................................................................. (888) 266-8080

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