Focus on life. Focus on health. Stay focused. MyChoice 2020 Member Guide 1 Welcome to BlueChoice HealthPlan This member guide will provide valuable information to help you get the most out of your health care coverage. We have created a “Benefits at a Glance” section to help get you started. Here you will find answers to some of the more common questions as you learn about your insurance coverage. To help you understand some of the terms used in health insurance, common insurance words are defined in the glossary on Page 43. Thank you for choosing MyChoice, and we look forward to providing you the highest level of service. Remember, we’re here to help you. If you need more information about anything in the Member Guide, or have other questions, please contact Member Services2018 in one of thesecon ways:2018 - Cumulie con - Cumulie2018 con - Cumulie QuickBill Bases QuickBill Physician’s Bases NewsQuickBillPhysician’s BasesNews Physician’s News Visit our website: Write to us: Or call Monday – Friday between Office Manual Office Manual Office Manual www.BlueChoiceSC.com BlueChoice HealthPlan 8:30 a.m. – 5 p.m.: Member Services 800-868-2528 P.O. Box 6170 TTY Services 711 + 800-868-2528 Columbia, SC 29260-6170 Other documents referred to in this Member Guide will help you better understand your specific coverage and benefits, such as your copayments for prescription drugs and office visits, exclusions, etc. Here’s how to access these documents: Laboratory Laboratory Laboratory This is a list of your unique coverage and benefits. The Schedule of Benefits includes Biometric Learning ManagementBiometric EducationLearning ManagementBenefits Biometric MgmtEducation Learning Benefits Management Mgmt Education Benefits Mgmt ScheduleofBenefits: Screening System Screening Center System ScreeningCenter System Center the benefit categories and what you will pay for each service. You can access this through our website at www.BlueChoiceSC.com by logging in to MyHealthToolkit®. The first time you go to My Health Toolkit, you will need to create an account by selecting RegisterNow. Once you have created an account, you will have access to your Schedule of Benefits and Certificate of Coverage. The Certificate of Coverage is an in-depth description of covered services, exclusions, limitations and eligibility requirements. Once in your account, you will need to select the Benefits tab at the top of the page, then the HealthEligibilityandBenefits link and then select ViewBenefitBooklet. You can also request a QuickEnroll FOCUSfwdQuickEnroll Great FOCUSfwdHearingQuickEnroll Aids Great FOCUSfwdHearing Aids Great Hearing Aids Employee BlueChoice My HealthBlueChoice RewardsMy Health BlueChoiceRewards My Health Rewards Tobacco Tobacco Producers DiscountsTobacco andProducers EmployeeDiscounts and ProducersEmployee Discounts and Expectations Expectations StorefrontExpectations Storefront Storefront Assistance copy ofHealthPlan your Certificate Wire ofToolkit HealthPlanCoverage Wire from MemberToolkit Services.HealthPlan Wire Toolkit Cessation Cessation Guide Added CessationValuesGuide AssistanceAdded Values GuideAssistance Added Values Program Program Program If you need an interpreter, we have free services available for both oral and written assistance. If you have questions about your coverage, please contact Member Services for more information. We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. Health Care Video Health Care Blue Video Business ADVHealthBlue Care BusinessVideo ADV Blue Business ADV Blues Flash Core ServicesBlues FlashMedical PoliciesCore Services BluesMedical Flash Policies Core Services Medical Policies Flexible Savings Health Flexible Savings Health Flexible Savings Health Advantage Plus Carolina ADVAdvantage MyChoicePlus ADVCarolina ADVPrimary ChoiceAdvantageMyChoice PlusADV CarolinaPrimary ADV Choice MyChoice ADV Primary Choice Mobile Mobile Reform Mobile Reform Option ReformOption Option App Account App Reimbursement Account ReimbursementApp Account Reimbursement Account Account Account RV: 228 RV: 228 RV: 228 Table of Contents Preventive Health Guidelines ............................................ 3 When Is an Emergency Not an Emergency? ................... 17 Great Expectations® for health programs ...............................3 Employee Assistance Program (EAP) Services ................ 18 Information on the Web .................................................... 4 Counseling Sessions ...............................................................18 My Health Toolkit ......................................................................4 Life Management Services .....................................................18 What’s Included? .......................................................................4 If You Need to See A Doctor ........................................... 19 Download the My Health Toolkit App Today .........................4 Your Personal Physician ..........................................................19 Help Wanted ..................................................................... 5 Routine Care ............................................................................19 Gynecologist (GYN) ................................................................20 FOCUSfwd ® Wellness Incentive Program .......................... 6 When You Need to See a Specialist .....................................20 ® FOCUSfwd Device Integration ......................................... 7 Other Health Care Providers..................................................21 FOCUSfwd® GET FIT Challenge ......................................... 7 What We Pay For.....................................................................21 What We Do Not Pay For .......................................................21 Personal Health Assessment ............................................. 8 A Step Toward Better Health ...................................................8 If You Need a Prescription Drug ...................................... 22 Your Privacy Is Our Priority .......................................................8 Special Circumstances — Quantity Limits, You Matter..................................................................................8 Step Therapy and Prior Authorization ..................................23 Instant Feedback .......................................................................8 Quantity Limits and Step Therapy Requirements ...............23 How to Access ...........................................................................8 Prescriptions Requiring Prior Authorization .........................24 Specialty Drugs ...................................................................... 24 Visit With a Doctor Anytime, Anywhere ........................... 9 Additional Pharmacy Considerations ...................................24 What Types of Conditions Can Blue CareOnDemandSM Doctors Treat? .................................9 Our Commitment to You ................................................. 25 When Should You Use Video Visits .........................................9 Covering New Technology .....................................................25 Get Started Now .......................................................................9 Privacy Practices ......................................................................25 Questions and Concerns ........................................................26 How Your Health Care Coverage Works ......................... 10 Subrogation .............................................................................26 Using Your Member ID Card ..................................................10 Rights and Responsibilities ....................................................26 Your ID Card Is Digital, Too ....................................................10 Advantages of Your Digital ID Card ......................................10 Policies and Procedures ................................................... 28 How to Access Your Digital ID Card .....................................10 Appeals and External Review Procedures ............................28 If You Need To Be Admitted to the Hospital .......................10 Submitting Claims ...................................................................28 If You Need Emergency Care ................................................10 Authorization to Disclose Form ....................................... 29 Lab Work, X-Rays and Pathology ..........................................12 Vision Care ...............................................................................12 Notice of Our Privacy Policies and Practices ................... 31 Behavioral Health ....................................................................12 Open Access Benefits ...................................................... 36 When You Travel ......................................................................13 Value Plan Benefits .......................................................... 40 Out-of-Network Benefits ........................................................13 What You Pay ...........................................................................13 Non-Discrimination Statement and EOB ..........................................................................................14 Foreign Language Access ...........................................