Your. Blue Book. What is covered and all the rest you need to know about your health insurance. bcnepa.com IND

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1 Your Blue Book What is covered and all the rest you need to know about your health insurance IND bcnepa.com

2 Welcome to Blue Cross of Northeastern Pennsylvania! Count on us to help you every step of the way. We are committed to giving you and your family the resources you need for good health. We re here for you, with preventive services to keep you well and the coverage you need when you re sick or injured. Our health insurance gives you the benefits you want and the quality health care you deserve, and we make it simple to access and manage your care. Best of all, you get all this at an affordable price. Be sure to take a look at everything in this Blue Book Remember: Your Blue Book intends to help you understand your insurance. It does not take the place of your Policy and the Outline of Coverage. The Policy is the final say as to what is covered, the process you have to follow to get care and the costs you must pay. Also included is Your Service Book. It gives you step-by-step instructions for using the many resources available on our website and explains how to get the most from our online Self-Service solution. bcnepa.com

3 The Blue Cross on the rooftop of our headquarters 19 North Main Street, Wilkes-Barre 84% of our members would recommend bcnepa to others * What you ll find inside 2 Learn about your coverage Your Policy, Your Member Handbook and Your Blue Book 4 The value of Blue 6 When you need care, we ve got you covered Your ID card 7 When you need care right now! Emergency and urgent care 8 Getting care from doctors you know and trust 10 Some examples of out-of-pocket costs 14 Keeping or changing your coverage Changes in benefits Eligibility Dependent coverage 16 Coverage from other health insurance plans Coordination of Benefits (COB) 17 We take our responsibilities very seriously Complaints and grievances How we protect your confidential information HIPAA and your medical records 21 Need some help? Call us * 2013 BCBS Member Satisfaction Survey of members enrolled in individual and traditional health insurance plans Your Blue Book 1

4 Learn about your coverage An explanation of what you can expect from your experience with Blue Cross of Northeastern Pennsylvania and how you can improve that experience is included in our Members Rights and Responsibilities at bcnepa.com/members/rights.aspx. All of our individual health insurance plans offer the same great benefits, including the Essential Health Benefits required by the Affordable Care Act. Your Member Handbook gives you a brief summary of the covered benefits that are part of your Policy. The Policy is the final say as to what is covered and not covered, the process you have to follow to get care and what you have to pay. A copy of your Policy is included with this handbook kit. Remember: Some services require prior approval from BCNEPA before they are given to you. Services that require prior approval are explained in Your Member Handbook, and in your Policy as services needing precertification. More resources can be found online at bcnepa.com. Click on Enter Member Homepage, then My Insurance Plan and select your health insurance plan. 2 bcnepa.com

5 Where do you go to get the total picture of what s included with your insurance? Your Policy, Outline of Coverage and Your Member Handbook explains which benefits are covered and which are not Your Policy With this handbook kit, you will find a copy of your Policy. The Policy: Is a legal agreement that gives you the most detailed information about your health insurance, including the benefits and services that are covered Lists your deductibles, coinsurances and/or copays for services, along with the Outline of Coverage and any endorsements or riders Explains any benefit maximums Lists exclusions the services and care that are not covered Is held between you and First Priority Life Insurance Company Your Member Handbook Your Member Handbook is enclosed. It explains: The basics you need to know A brief summary of your covered medical benefits and services Your Blue Book Having quality health insurance is important. But knowing how to use your health insurance is essential. Your Blue Book helps you get the most from your coverage, whether you re sick or healthy. The preventive services that are covered most at no cost to you What you ll pay for care from in-network doctors and those not in-network How to get care when you are outside our service area When you need to get prior approval for care and how to get it How we make sure you get quality care with medical care review When you may need to file a claim and how to do it Your Blue Book 3

6 The value of Blue By choosing Blue Cross of Northeastern Pennsylvania, you have the security and peace of mind that only comes with Blue Cross health insurance. No other health insurer offers the national strength of Blue combined with our strong local commitment. Blue Cross of Northeastern Pennsylvania is the most trusted name for robust health care benefits, quality care, the largest networks of doctors and hospitals, outstanding customer service and unbeatable value since Only with Blue Cross of Northeastern Pennsylvania health insurance, you get: Coverage that s easy to use Just show your Blue Cross of Northeastern Pennsylvania ID card it s like your VIP pass for the best coverage and top quality care from the most respected doctors and hospitals. Use in-network doctors and hospitals and you ll pay the lowest cost for your care. The best coverage With Blue Cross of Northeastern Pennsylvania you can rest easy knowing you re covered preventive care at no cost to you and low-cost doctor visits, prescription drugs, hospital stays and more. The largest networks of doctors and hospitals ANYWHERE You ll have access to the largest networks of the most respected doctors and hospitals close to home and anywhere you travel. In most cases, your doctor is in your plan s network. And because our plans offer more freedom than competitors, you can see doctors out of your plan s network, and you ll still receive valuable coverage you ll just have to pay a little more for your care. Lower costs with care from in-network doctors and hospitals When you see in-network doctors and hospitals, you will always pay less. That s because our in-network providers have agreed to see Blue Cross of Northeastern Pennsylvania members at a discounted rate. In fact, because Blue networks nationwide include 96% of all U.S. hospitals including several Blue Distinction Centers, recognized for a proven history of quality care and fewer avoidable complications and 92% of all U.S. doctors, we ve negotiated better rates than competitors. This means you will pay less for your care, with a Blue plan. Coverage anywhere you go worldwide With BlueCard doctors and hospitals in every ZIP code across the U.S. and in 200 countries worldwide Blue members have access to top-quality health care and coverage EVERYWHERE! In some cases, you ll pay the same for care as you would at home. And you ll always pay less when you use the BlueCard providers because they offer Blue members care for less than they typically charge. That s security that travels with you and value that only comes with coverage from Blue Cross. Rewards for wellness Our plans help you get healthy and reward you for doing so. Only with a Blue plan you get exclusive discounts on fitness classes, nutrition counseling, massages, travel and more with Blue 365. With Blue Health Solutions SM, you have your own personal health coach a licensed health professional, registered nurse or dietician to help you manage a chronic condition or stress, offer tips and more. Health professionals are always available by phone, 24/7. 4 bcnepa.com

7 These books are included to help you better understand your coverage Your Network Book The doctors and hospitals you use have a big impact on your costs. This book explains how your PPO provider network works and how you can save money when you use in-network doctors, hospitals and providers. The Difference Is Clear This book explains how you can find network doctors and hospitals using our online directory. The directory features quality and cost information and comparisons for network doctors and hospitals. Your Service Book This book gives you step-by-step instructions for using the many resources available on our website and explains how to get the most from our online Self-Service solution. Your Wellness Book Blue Health Solutions is your health and wellness resource. This book explains how Blue Health Solutions health management, care management and wellness and lifestyle resources can help you and your family to achieve better health. Your prescription drug brochure A prescription drug brochure is included with this handbook kit. It outlines your specific drug coverage and explains how the drug formulary works. To see your coverage, claims details and out-of-pocket costs anytime, register or logon to Self-Service at bcnepa.com and select the My Coverage tab. Your Blue Book 5

8 When you need care, we ve got you covered Your ID card is key when you need care. Show your ID card every time you or a covered family member receives care Always use your most current ID card Most member ID cards look like the samples below. Because your ID card is so important, be sure the information on it is correct. Read and keep the card carrier, too. Both the ID card and the carrier have valuable information about your coverage. If your card is ever lost or stolen, let us know immediately. Front of ID card Rx drug information JOSEPH DOE QFL Plan Code Rx ID Rx Group Rx PCN Rx BIN ID number FE BLPA01 A Plan myblue Choice PRIMARY COPAY SPECIALTY COPAY $20 $40 Plan name Doctor and ER copays PPO See your policy for covered services. This card does not guarantee eligibility for benefits. Providers: All claims must be filed with your local Blue Cross or Blue Shield Licensee. Visit for online services and health-related information. Service Representatives: (TTY): Out-of-Area Care: BLUE (2583) Pharmacy Benefits: /7 Nurse Now: BLUE (2583) Providers: BlueCard Eligibility: BLUE (2583) Precertification: Mental Health/Chemical Recovery: Pharmacists Call: First Priority Life 19 North Main St. Wilkes-Barre, PA Customer Service Back of ID card Pharmacy Benefits Administrator 6 bcnepa.com

9 When you need care right now! Call 911 Emergency services are available 24 hours a day, 7 days a week Emergency care If you need emergency care, get treatment immediately. The emergency care doctor does not have to get prior approval from us for outpatient emergency services Emergency services are covered when the services meet the conditions of emergency care, as defined in your Policy You will be covered if you need to be admitted to a hospital that does not participate with us. Once your condition has stabilized, your care may be transferred to an in-network hospital You have to pay the ER copay, coinsurance and/or deductible that apply, as listed in your Outline of Coverage If you need emergency care for a behavioral or mental health concern, you should get treatment immediately at the nearest ER. Your primary care doctor might be able to help. In some cases, your primary care doctor might be your best resource. If you need treatment fast, but don t feel your care requires an emergency room visit, call your primary care doctor. Urgent care centers If you or a family member becomes sick or hurt, knowing where to go for care will save you time and money. We encourage you to contact your primary care physician whenever possible. But, if your doctor is not available, the ER is not your only option. The ER can be very expensive and your care might not be covered by your plan if it s not considered an emergency. When you need care and your doctor is unavailable, consider an urgent care center which is a convenient and cost-effective alternative for care that is not for an emergency. These facilities are clinics that give unscheduled, walk-in care for a sickness or injury, outside of a hospital ER. These facilities are staffed by doctors, nurses, physician assistants and other medical professionals. For the lowest out-of-pocket costs for care, you should use in-network urgent care centers. In-network urgent care centers are listed in Your Member Handbook and online at bcnepa.com. If you use an urgent care center out of the network, we will pay for services according to how the center bills the visit. For example, it may be billed as an ER visit, outpatient visit or office visit. You would have to pay any out-of-pocket costs that apply. Keep in mind, out-of-network urgent care centers may still cost you less than if you get treated in the ER for care and services that are not for an emergency. For more information on out-of-pocket costs for care from ERs and urgent care centers, see your Outline of Coverage. Your Blue Book 7

10 Getting care from doctors you know and trust We make it easy Compare cost and quality for network doctors and hospitals at findadoctor.bcnepa.com 96% of all U.S. hospitals and 92% of all U.S. doctors are in Blue networks In-network providers offer quality care at the lowest cost In most cases, your costs for all care will always be the lowest when you use in-network providers (doctors and hospitals). With most of our health insurance plans, coverage is provided for care out of the network, but at a higher cost out of your own pocket. In-network providers are respected professionals who must meet rigorous standards before they can join our network. They are reviewed by us on a regular basis, so you are sure to get high-quality care. In-network providers: Have agreed to see our members at a discounted rate and accept our allowable charge as payment in full, less your copay, coinsurance and/or deductibles Accept our decision on medically necessary services, and you will not receive a bill for those costs (except for the deductibles, copays and coinsurance you must pay). However, any service that Blue Cross has determined to be not medically necessary will be your responsibility to pay in full, if you choose to move forward with that service In most cases, will coordinate all prior approvals for you, but it s still a good idea to ask to be sure your services are approved before you receive care Will submit all claims and paperwork for you, so you don t have to Your Member Handbook and Your Network Book offer more information about using in-network providers and what it costs when you use providers out of the network. 8 bcnepa.com

11 Where can I find in-network providers? Our online directory, Doctor/Hospital Finder, gives you several ways to search for doctors, specialists, hospitals, urgent care centers and other medical facilities. You ll also find valuable cost and quality-of-care information and reviews of doctors. For questions about a doctor s medical school, residency or board certification, call Customer Service, weekdays, between 8 a.m. and 5 p.m., at To learn more, go to findadoctor.bcnepa.com. Learn more about ratings and costs in The Difference Is Clear, included with this handbook kit. Primary care doctors It s a good idea to establish a relationship with a primary care doctor to: Coordinate your care and manage your treatment plans Help you choose specialists and other providers, if you need them Make sure you get the most appropriate care in the most appropriate setting Your primary care doctor is your first point of contact when you need care. Primary care doctors are also available to help you in urgent situations. All have coverage arrangements 24 hours a day, 7 days a week. Find a doctor you re comfortable with If you don t have a primary care doctor and need help finding one, call Customer Service, weekdays, between 8 a.m. and 5 p.m., at , or go to findadoctor.bcnepa.com. Specialists In most cases, your primary care doctor will give you the care that you need. If you need care from a specialist, your doctor will recommend one that is in-network, or you can select a specialist on your own. Keeping your doctors informed If you see more than one doctor for care, it s important to keep all of your doctors informed about your care to ensure your safety and to avoid having and paying for services that aren t needed. You re covered, even when you re far from home Your health insurance travels with you almost everywhere in the world with BlueCard PPO. That s something no other health insurer can offer. Just take your card when you travel and show it to any participating Blue Plan doctor or hospital. Each plan offers different BlueCard PPO coverage. See Your Member Handbook for your plan-specific out-of-pocket costs for care. To find a BlueCard PPO network doctor, hospital or facility when you travel, go to bcnepa.com/finddoctorhospital.aspx. It s that easy! Your Blue Book 9

12 Some examples of out-of-pocket costs With health insurance, you have to pay for some of the costs of your care, and your health insurance will, in most cases, pay for most of the cost of your care. Your health insurance plan has a monthly cost. It s called a premium. You have to pay your monthly premium each month to your insurer to keep your health insurance plan. Aside from a monthly premium, you also have to pay a share of the cost when you receive care. Your Outline of Coverage, included with this handbook kit, lists exactly what is covered and how much you are required to pay when receiving covered services. Your out-of-pocket costs depend on your specific insurance plan. To learn more about our PPO provider networks and how you can save money, read Your Network Book. Out-of-pocket costs when you receive care Out-of-pocket costs include copays, deductibles and coinsurance. How much you have to pay and when each applies differ by plan. And your plan s network of doctors and hospitals and who you choose to see for care also impact your out-of-pocket costs. Copay How much you must pay for covered medical care (such as office visits and prescription drugs). For example, if your plan has a $20 copay for office visits, you will pay $20 each time you see your doctor. Deductible Individual How much you must pay when you get care (such as lab services, X-rays and physical therapy) before your health insurance will start to pay for covered medical care. Once you ve paid up to your deductible amount in care costs, you won t pay any more towards your deductible that year. Families If you have family members covered on your plan, all family members contribute to a family deductible typically double the amount of the individual deductible. This means that if you and your family members combined costs for care come to an amount that reaches the family deductible, no one in your family has to pay anything more towards their individual deductible for the rest of the year. The higher the deductible, the lower your monthly premium Deductibles for care from in-network doctors will always be lower than deductibles for care out of the network No family member will ever pay more than his/her individual deductible, while contributing to the family deductible 10 bcnepa.com

13 Coinsurance This is your share (%) of the cost for covered medical care (such as hospital stays and outpatient services). For example, your health insurance may cover 80% of the charges for a hospital stay. You have to pay the other 20%. This 20% is your coinsurance. Coinsurance for care from in-network doctors will always be lower than coinsurance required for care from doctors out of the network Out-of-pocket maximum Individuals This is the most you have to pay out of your own pocket for covered services within the year. This means that once the amount you spend on copays, deductibles and coinsurance combined, reaches the maximum amount, you will NOT have to pay for covered medical care. Your care will be covered at 100% for the rest of the year. Families If you have family members covered on your plan, this is the most you and all your covered family members combined have to pay out-of-pocket for covered services within the year. This amount is typically double the individual out-of-pocket maximum. This means that once the amount you and covered family members spend on copays, deductibles and coinsurance combined reaches the family maximum, you and all covered family members will NOT have to pay for covered medical care for the rest of the year even if individual family members have not yet met their individual out-of-pocket maximum. The out-of-pocket maximum for care from in-network doctors will always be lower than the out-of-pocket maximum for care from doctors out of your plan s network No family member will ever pay more than his/her individual out-of-pocket maximum, while contributing to the family out-of-pocket maximum Out-of-pocket costs and maximums differ by plan. Be sure to see the Outline of Coverage included with this welcome kit for plan-specific costs and maximums. Your Blue Book 11

14 Here are some examples of how cost sharing works* Cindy has myblue Choice $1,000 coverage with Blue Cross of Northeastern Pennsylvania. Her Outline of Coverage says she is responsible for paying the following cost-sharing amounts for care: Primary care doctor visits $20 copay Annual deductible $1,000 Coinsurance 20% I ll never go without Blue Cross insurance. It makes all the difference! 1 Cindy sees her primary care doctor for a routine office visit. She pays only the $20 copay at the time of the visit. I m glad I went to see my doctor when I did waiting could have made things worse. With a $20 copay, I didn t have to worry about being able to afford good care. Receipt for office visit Office visit, primary care doctor Cost of visit $150 The in-network provider accepts BCNEPA s allowable charge $110 Cindy pays her copay $20 BCNEPA pays the rest $90 Cindy s total cost $20 * These examples are for illustrative purposes only. They do not reflect any actual situations or payments involving Blue Cross members. Since no deductible or coinsurance applies, Cindy pays only the copay. 12 bcnepa.com

15 2 Later that year, Cindy has knee surgery. The cost for services is $10,000, but her in-network doctor agrees to the allowable charge and bills only $8,500 for Cindy s care. Since Cindy had no other medical expenses this year that were applied to her annual deductible, she will have to pay $1,000, the full amount of her deductible, toward this bill before her health insurance will pay. Receipt for surgical services Knee surgery, in-network Cost of service $10,000 The in-network provider accepts BCNEPA s allowable charge $8,500* Besides the deductible, Cindy s insurance requires 20% coinsurance. Cindy pays her annual deductible $1,000 Balance due $7,500 This means that, after the deductible is met, Cindy will have to pay only 20% toward her medical care costs. Her Blue Cross coverage will pay the rest. I was really scared but the staff were great and I knew I didn t have to worry about my insurance being accepted. Blue Cross is a name to trust. Cindy pays a 20% coinsurance $1,500 BCNEPA pays the rest $6,000 Cindy s total cost using an in-network provider $2,500 * If Cindy had used an out-of-network provider, she would also be responsible for paying an additional $1,500, which is the difference between the cost of service and BCNEPA s allowable charge. Cindy s annual deductible has now been met. She will now have to pay only copays and coinsurance costs. 3 Receipt for physical therapy 12, one-hour sessions, in-network Following her surgery, Cindy s doctor sends her to physical therapy. Because she already met her deductible for the year, Cindy will only have to pay her 20% coinsurance toward physical therapy costs. Her Blue Cross coverage will pay the rest. Cost of service $2,000 BCNEPA s allowable charge $1,750 Cindy pays a 20% coinsurance $350 BCNEPA pays the rest $1,400 Cindy s total cost using an in-network provider $350 My procedure was simple, but I was surprised at the cost. I don t know what I would have done without Blue Cross they paid 80%! And they gave me peace of mind during a difficult time. Annual deductible has been met. No copay. Cindy has only a coinsurance payment. * These examples are for illustrative purposes only. They do not reflect any actual situations or payments involving Blue Cross members. Your Blue Book 13

16 Keeping or changing your coverage Changes in benefits To offer the best health care possible and keep the cost of care affordable, we continually review your benefits and may make changes as needed. We may offer new services and benefits, or eliminate others We may make changes to improve services and help keep costs from rising We will share benefit changes with you before the date of the change Eligibility To keep this health insurance plan, you must: Keep a legal residence in our service area for at least 9 months of the year Pay your premium when due, or within the grace period allowed Your specific eligibility requirements are explained in your Policy. Dependent coverage We consider a dependent to be a spouse or a child, including: Newborns Stepchildren Adopted children Foster children Children who are dependent on you for support because of a physical or mental handicap See your policy for covered services. This card does not guarantee eligibility for benefits. Providers: All claims must be filed with your local Blue Cross or Blue Shield Licensee. Visit for online services and health-related information. Service Representatives: (TTY): Out-of-Area Care: BLUE (2583) Pharmacy Benefits: /7 Nurse Now: BLUE (2583) Providers: BlueCard Eligibility: BLUE (2583) Precertification: Mental Health/Chemical Recovery: Pharmacists Call: First Priority Life 19 North Main St. Wilkes-Barre, PA Customer Service phone numbers Pharmacy Benefits Administrator 14 bcnepa.com

17 Need to make a change to your dependent coverage? Just call Customer Service, weekdays, between 8 a.m. and 5 p.m., at To add a dependent to your Policy, you must qualify for a Special Enrollment period. This short period of time, typically 60 days, starts on the date of the qualifying life event and ends 60 days later. If you do not change your health insurance plan within your Special Enrollment period, you must wait until the next Open Enrollment period to change coverage. Qualifying life events for changing dependent coverage include: You got married Reasons your coverage might end Your coverage and the coverage of your dependents may end (terminate) if: The premium is not paid Eligibility requirements are not met You used your ID card fraudulently to get benefits, or made false statements on your application for coverage You had a baby, adopted or placed a child in foster care Your dependent involuntarily lost their health insurance coverage (for example: because they lost their job or their employer dropped their health insurance coverage) You can learn about Special Enrollment and qualifying life events at BlueCrossNEPAStore.com/learn. Access to your dependents information The Health Insurance Portability and Accountability Act (HIPAA) limits how we use an individual s personal health information (PHI). To access PHI of your covered spouse or covered children who are over the age of 18, you must fill out and send us an Authorization form. Go to bcnepa.com/privacy.aspx Read the instructions Print the form, fill it out and mail the completed form to: Privacy & Security Office Blue Cross of Northeastern Pennsylvania 19 North Main Street Wilkes-Barre, PA Or call Customer Service, weekdays, between 8 a.m. and 5 p.m., at Your Blue Book 15

18 Coverage from other health insurance plans Other insurance programs In some cases, an injury you receive will be covered by other programs or insurers: Auto insurance If you are injured in an auto accident, you should send medical bills related to the care you received to your auto insurance carrier Workers Compensation If you, your spouse or a covered dependent is employed and has an accident or injury at work, you should work through the employer to have any related medical expenses covered through Workers Compensation Medicare If you, your spouse or your dependents are eligible for Medicare due to age or disability and have questions about what is covered, please call MEDICARE ( ) Coordination of Benefits (COB) When you enrolled, you were asked to tell us if you were covered by another health insurance plan (for example, through your spouse s employer). COB takes place when you are covered by 2 health care plans. It helps us to make sure the correct insurance plan pays for your services. Here s how it works for you: If you are covered as the Policy holder on a health insurance plan and as a dependent on another plan (often, your spouse s plan), the coverage that lists you as the Policy holder would be considered primary If another plan is your primary plan, your medical expenses should be sent to that plan first And for your dependent children: If a dependent child is covered under 2 health plans, his/ her expenses will be the responsibility of the plan that covers the parent whose birthday (month and day) comes earliest in the year Then, if the medical expenses are not covered in full by the primary plan, you can send them to the other plan and it may pay the costs not covered by the primary plan, if the services were appropriately approved To consider your claims as the secondary insurer, send us the Explanation of Benefits (EOB). You should receive an EOB from the other health insurance plan. Mail the EOB to: First Priority Life Claims Department P.O. Box Camp Hill, PA bcnepa.com

19 We take our responsibilities very seriously Complaints and grievances We have procedures in place to ensure that you receive fair and confidential treatment. A complaint is a dispute or objection about a network provider; coverage issues, including contract exclusions, limitations and non-covered benefits; and the operations and management policies of your coverage plan A grievance is a request for a review of the denial of a health care service based on medical necessity and appropriateness Here s how it works: If you have a concern, you should call Customer Service to see if the issue can be resolved quickly. The number is on the back of your ID card If the issue cannot be resolved to your satisfaction, you can file a complaint or grievance. The process for filing is explained in your Policy You also have the right to appeal a decision and to designate a representative to help you Resolutions of all disputes about denial of payment for a health care service will be made by qualified personnel with experience in the same or similar scope of practice. All notices of decisions will include information about why the decision was made Your Blue Book 17

20 Learn more about our privacy practices or download a HIPAA Authorization form at bcnepa.com/privacy.aspx. How we protect your confidential information We are committed to keeping your private and privileged information safe, secure and confidential. We only use your information as part of our business operations to: Give you covered benefits Make certain you receive quality care Ensure and improve service quality Identify your health care needs 18 bcnepa.com

21 Our policies We have policies in place to make sure your medical information and records are secure. Information in your medical records received from doctors, other network health care practitioners, hospitals and health professionals who are part of the doctor/ patient relationship is kept confidential This information may be released for use of valid medical research and education, as required by law or to collect statistical data For statistical data, this information is gathered and reported for the entire population being studied and is not member-specific Any additional release of information requires your authorization For those situations in which you are unable to give authorization, we will require appropriate documentation of the appointment of a member representative (e.g., power of attorney, guardianship document, court order or short certificate) We will not release your medical information outside Blue Cross, except for payment, treatment and health care operations, without your written authorization. This gives you the opportunity to approve the release of your medical information. Our employees Each year our employees receive a Statement of Corporate Ethics and Code of Business Conduct that explains their responsibilities for keeping your medical information private and secure. Our employees also receive annual Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security training and must confirm their understanding of the importance of safeguarding your member information. Our vendors We also have contracts with vendors, requiring them to make certain that your information is kept private and protected. Any information shared with a fully insured employer is reported on the entire group, not on an individual basis, to maintain confidentiality. City Hall, Williamsport We will always ask for your authorization in these situations: When requests for information are received from someone other than you When information that identifies you will be shared with another company or individual that is not involved in providing your care or benefits For the release of any information related to mental health, substance abuse or AIDS You can count on Blue Cross of Northeastern Pennsylvania to keep your personal health information safe and secure. Your Blue Book 19

22 In accordance with HIPAA We have physical, administrative and technical safeguards in place to protect your oral, written and electronic protected health information. This includes, but is not limited to: Keeping our facilities secure Keeping the systems that contain your information secure Putting in place confidentiality and business associate agreements with any vendors that we share your information with Securing the information that is sent electronically Verification processes to make certain that your information is only released to individuals who have the authority to receive it Your medical records You have the right to access the information that is contained in your medical records, unless access is specifically restricted by your doctor for medical reasons. If you need a copy of your medical records, call your doctor for a copy. And, finally, if you have any concerns about the confidentiality of your information, you have the right to file a complaint. More information about our privacy practices is explained in the enclosed Notice of Privacy Practices for Your Protected Health Information. 20 bcnepa.com

23 Need some help? Call us The answers to most of your questions can be found at bcnepa.com/members/mycoverage.aspx. Register/logon to Self-Service at bcnepa.com to see your coverage, claims details and out-of-pocket costs, anytime Send a secure to Customer Service from Self-Service Download our Self-Service mobile app to access information anytime, anywhere from bcnepa.com/mobile Call Customer Service. We re here to help you, weekdays, between 8 a.m. and 5 p.m. at or (TTY) These numbers are also on the back of your ID card. We also offer language interpretation services for members who do not speak English See your policy for covered services. This card does not guarantee eligibility for benefits. Providers: All claims must be filed with your local Blue Cross or Blue Shield Licensee. Visit for online services and health-related information. Service Representatives: (TTY): Out-of-Area Care: BLUE (2583) Pharmacy Benefits: /7 Nurse Now: BLUE (2583) Providers: BlueCard Eligibility: BLUE (2583) Precertification: Mental Health/Chemical Recovery: Pharmacists Call: First Priority Life 19 North Main St. Wilkes-Barre, PA Customer Service phone numbers When you need answers, we ve got you covered. See how easy it is to get the service you deserve with the enclosed Your Service Book. The Blue Cross Store, Dickson City Pharmacy Benefits Administrator Visit us in person. Blue Cross of Northeastern Pennsylvania retail stores are open, weekdays, between 8 a.m. and 5 p.m., at 3 locations Bartonsville Plaza 292 Frantz Road, Suite 109 Bartonsville, PA Park Center 1019 Commerce Blvd. Dickson City, PA TJ Maxx Plaza 1754 East 3rd Street Williamsport, PA The Blue Cross Store, Bartonsville Our Corporate Headquarters is open weekdays, between 8 a.m. and 5 p.m. Corporate Headquarters 19 North Main Street Wilkes-Barre, PA Get the most from your health insurance Your Blue Book was developed to give you a basic understanding of your covered benefits, using language that we hope is both easy to read and educational. It s just as important that you read Your Member Handbook, your Policy and all the other information that comes with this kit. We are committed to giving you and your family the resources and support you need to get the most from your health insurance. We value your satisfaction and look forward to meeting your health insurance needs now and in the years to come. Learn more about Health Care Reform and what it means for you and your family on BlueCrossNEPAStore.com/learn. Your Blue Book 21

24 This book contains general information about your coverage. The complete terms and conditions are in the contract/policy between you and First Priority Life Insurance Company. Final interpretation of any specific provision is governed by the contract/policy. Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers need for affordable healthcare. Individual outcomes may vary. National criteria is displayed on A Local Blue Plan may require additional criteria for facilities located in its own service area. For details on Local Blue Plan Criteria, a provider s in-network status, or your own policy s coverage, contact your Local Blue Plan. Each hospital s Cost Index is calculated with data from its Local Blue Plan. Hospitals in CA, ID, NY, PA, and WA may lie in two Local Blue Plans areas, resulting in two Cost Index figures; and their own Local Blue Plans decide whether one or both Cost Index figures must meet BDC+ national criteria. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for damages or non-covered charges resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers. Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan issuer in the Federally Facilitated Marketplace. Blue Cross of Northeastern Pennsylvania administers health plans for Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health and First Priority Life Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. Registered Mark of the Blue Cross and Blue Shield Association. CN-05B /14 Blue Cross of Northeastern Pennsylvania bcnepa.com