HOW CAN I HELP YOU?

Create an account or sign in to MyBlue to see the status of your deductible (if you have one). Your most recent Explanation of Benefits also shows deductible amounts met for the current year. Please contact Member Service at the number on the front of your ID card if you have questions about your deductible.

Your copayments for medical services are shown at the bottom of your ID card.

If you have a pharmacy benefit, you will need to identify your pharmacy benefit administrator in order to determine your copayment for each medication you receive. The name of your pharmacy benefit administrator (e.g., Express Scripts, Inc.) is printed on the back of your member ID card on the bottom of the card. To obtain your copayment amount, you can present this information to your pharmacist or sign in to your MyBlue account, and then click Review Your Benefits.

If your pharmacy benefit administrator is not displayed on the back of your ID card, you can contact your employer for this information or call Member Cervice at the number on the front of your ID card.

Your copayments are usually a fixed dollar amount (for example, $10, $20, or $30) you pay each time you use a particular medical service or fill a prescription. Copayments are usually due at the time you have an office visit or fill a prescription.

Medical services that may have copayments include:

• Office visits
• Mental health provider visits
• Emergency room visits
• Create an account or sign in to MyBlue for detailed information about your benefits.

Also known as cost-sharing, co-insurance is the portion of eligible expenses that plan members are responsible for paying, typically after the deductible is met. Co-insurance is usually a percentage of the provider's actual charge, or the allowed amount.

If you are an HMO Blue^®, HMO Blue New EnglandSM, Blue Choice^®, or Blue Choice New England^SM member, you must choose a PCP. Your PCP is your partner in guiding you through the health care system. In addition, your PCP will serve as your health care advisor when you have questions or need treatment, and will make sure you receive the care you need.

By coordinating your care through a PCP, you can develop a relationship with a trusted health care provider who will become familiar with your health care concerns. If you need a specialist, your PCP can refer you to one—and give your specialist background about your condition and any previous treatment you may have had.

While not all of our plans require that you choose a PCP, having one is a great way to make the most of your Blue Cross Blue Shield of Massachusetts coverage.

Choosing your PCP is important, and there are several factors you should consider when making your decision. You might want a PCP with a particular subspecialty, such as gastroenterology or cardiology, or perhaps you want a PCP who is affiliated with a particular hospital. You might be more concerned with your PCP's education, or maybe location or public transportation access matters to you most. Before choosing a PCP, make a list of the things that are most important to you. Then you can find a PCP in one of three ways:

• Use our Find a Doctor & Estimate Costs service and create your own Provider Directory.
• You can obtain a Provider Directory for your plan by calling 1-800-262-BLUE (2583).
• You can also call our Physician Selection Service at 1-800-821-1388 if you'd like help selecting a PCP.
• Once you select a PCP, create an account or sign in to MyBlue to designate your PCP, or call Member Service at the number on the front of your ID card.

If you are an HMO Blue member and receive services without choosing a PCP, those services will not be covered. A PCP must be noted for services to be covered and paid. If you are a Blue Choice member, you should have a PCP on our records, even though you may wish to see providers who are not in the network. Please note that Blue Choice members incur higher out-of-pocket expenses when they self-refer.

Yes. Each member of your family should choose a PCP who best suits their needs. Our New England plans include PCPs in all six New England states.

Yes. All HMO Blue and HMO Blue New England members must get a PCP referral before seeing a specialist. Because your PCP knows your history and health care needs, he or she is best qualified to help you decide whether a specialist is needed. Blue Choice and Blue Choice New England members have the option to self-refer for covered services at a higher out-of-pocket cost.

Always discuss your concerns with your PCP. Your PCP will work with you to explore all the available options and make sure your medical needs are met.

Blue Cross Blue Shield of Massachusetts does not offer incentives to limit your care. That means your PCP concentrates on making sure you receive appropriate care in the right setting.

If you have a condition that requires prompt treatment but can wait for the time it takes to contact your PCP for direction, this is considered urgently needed care. A sprained ankle, earache, and a fever are examples of urgently needed care.

You may need emergency care because of the sudden onset of a condition with acute symptoms, including severe pain, which are severe enough that the lack of prompt medical attention could reasonably be expected by a prudent layperson, who has an average knowledge of health and medicine, to result in placing your health or the health of another (including an unborn child) in serious jeopardy. A suspected heart attack, stroke, poisoning, loss of consciousness, convulsion, and a suicide attempt are examples of medical emergencies. If you need emergency care, go to the nearest medical facility or call 911 (or your local emergency number).

If you think you need to see a specialist, you should discuss it with your PCP. Your PCP will help you determine whether or not a specialist is needed and refer you to one who is best qualified to treat your condition.

Your network includes a comprehensive listing of doctors in a wide variety of specialties. If your doctor believes you need to see a type of specialist not included in the network, he or she may refer you to one outside the network and those services will be covered.

Finding a doctor is easy and can be done in one of three ways:

• Use our Find a Doctor & Estimate Costs service and create your own Provider Directory.
• You can obtain a Provider Directory for your plan by calling 1-800-262-BLUE (2583).
• You can also call our Physician Selection Service at 1-800-821-1388 if you'd like help selecting a PCP.
• Once you select a PCP, create an account or sign in to MyBlue to designate your PCP, or call Member Service at the number on the front of your ID card.

Yes. You may change your PCP at any time and as often as you choose. You do not have to specify a reason. Your change is effective immediately upon notifying us.

If you have an urgent health care need, call your PCP first. Your doctor will either treat you or advise you on what to do. All of our plan providers have 24-hour telephone coverage.

If you or a family member is having a life-threatening emergency, call 911 or your local emergency care service and get help immediately. Contact your PCP as soon as possible after you've been treated.

If you don't have a PCP and are concerned about coverage for your emergency care, just call the Member Service number on the front of your ID card—they're here to help.

If you need urgent or emergency care outside of our service area, go to the nearest health care facility. Call the Member Service number on the front of your ID card during the next business day.

If you need routine care (checkups, vaccinations, etc.) when traveling, check with Member Service before your appointment.

Because we are dealing with personal information, security is our top priority. For your protection, we have assigned all members a unique password. This safeguards your personal information, and gives you the exclusive ability to update it. We use the best web security practices available to ensure that your personal information is updated only by you.

Most young adults transition between the ages of 18 and 21. We can help with that. Check out our Find a Doctor & Estimate Costs tool to search for a new doctor for your child.

An independent clinical lab is a laboratory that is not part of a hospital or hospital-based facility. Independent clinical labs perform tests or procedures to help diagnose and/or treat medical conditions. Some examples of tests include blood tests, urinalysis, and Pap tests. Some examples of independent clinical labs include Quest Diagnostics and LabCorp.

A freestanding imaging center is an imaging center that is not part of a hospital or hospital-based facility. Freestanding imaging centers produce specialized images to help diagnose medical conditions. Imaging examples include X-rays, MRIs, and ultrasounds. Some examples of freestanding imaging centers include Shields MRI and Premiere Diagnostics.

There are several ways to find an independent lab or freestanding imaging center:

• Ask your doctor to refer you to a non-hospital provider
• Use the Find a Doctor & Estimate Costs
• Call Member Service at the number on your Blue Cross ID card
• Refer to the Diagnostic Tests and Imaging Centers section in your health plan Provider Directory

Costs for diagnostic tests and imaging services performed at hospitals or hospital-based outpatient centers are often among the highest. Your total cost of care will be lower and your out-of-pocket costs may be lower when you have your procedure performed at an independent clinical lab or freestanding imaging center. You’ll receive the same services, just at a different location.

First, contact Member Service at the toll-free number on the front of your ID card. A Member Service representative will explain your benefits, answer your questions, and work to resolve any problems you might be having. Most of the time, one call is all it takes to address your concerns.

If, after speaking with Member Service, you feel your issue is still not resolved, you may request a formal review through our Appeal Grievance Program. A grievance specialist will be assigned to your case and will guide you through the process. Learn more about the Appeal and Grievance Program.

If you or a family member is having a life-threatening emergency, call 911 or your local emergency care service and get help immediately. Contact your PCP as soon as possible after you've been treated.

If you don't have a PCP and are concerned about coverage for your emergency care, just call the Member Service number on the front of your ID card—they're here to help.

If you have an urgent health care need, call your PCP first. Your doctor will either treat you or advise you on what to do. All of our plan providers have 24-hour telephone coverage.

If you need urgent or emergency care outside of our service area, go to the nearest health care facility. Call the Member Service number on the front of your ID card during the next business day.

If you need routine care (checkups, vaccinations, etc.) when traveling, check with Member Service before your appointment.

If your plan requires that you choose a PCP, you must get a PCP referral before seeing a specialist. Talking with a PCP can also help you understand what's involved with specialty care if you need it.

If your plan doesn't require that you choose a PCP, you can see a specialist or other health care provider without a referral. However, you'll still need to see a provider who participates with Blue Cross Blue Shield of Massachusetts in order to have your benefits covered at the highest level.

Create an account or sign in to MyBlue to view your Summary of Benefits online. You can also call Member Service at the number on the front your ID card.

Your primary care provider (PCP) is the most important part of your health care team. With a comprehensive understanding of your medical history and conditions, your PCP will be your partner in everyday, preventive care, as well as the coordinator of any specialized care you may need. We believe collaborative relationships between you and our team of trusted, skilled doctors provide you with the best possible care.

Your PCP will be your advocate, no matter what your health needs. He or she collaborates with our team of trusted specialists to be sure you’re getting the care you need. This allows your PCP to ensure good communication and coordination among all the providers involved in your care.

Before you seek specialty care, be sure to contact us so we can arrange any specialty care you may need. If you have a request for medical care services outside of our group, you should discuss this option with your PCP. He or she will work with you to make a decision, keeping accessibility, timeliness, cost, and quality of care in mind.

While not all of our plans require that you choose a primary care provider, having one is a great way to make the most of your Blue Cross Blue Shield of Massachusetts coverage.

Each covered member of your family may choose his or her own primary care provider (PCP), and choosing the right one is important. There are many different types of PCPs, including general practitioners, internists, pediatricians, family medicine physicians, and nurse practitioners. To choose the best fit for you or your family member, begin by asking for recommendations from the people you trust. You should also consider each PCP’s distance and accessibility from your work or home. Most importantly, talk with us to be sure that the practice can meet your personal health care needs.

For the most up-to-date provider listings, call the Find a Doctor Support Line at 1-800-821-1388 or visit Find a Doctor & Estimate Costs.

Using the Find a Doctor & Estimate Costs tool, you can search for a PCP by:

• Gender
• Language(s) spoken
• Hospital affiliation
• Medical group
• Extended/weekend hours
• Electronic capabilities (e.g., electronic medical records, electronic prescribing, and web consultation)
• Once you select a PCP, you have to inform Blue Cross Blue Cross Blue Shield of Massachusetts. You can select your PCP by logging in and visiting the My Account section and selecting Change My Primary Care Provider, or call Member Service at the number on the front of your ID card.

In general, you may change your PCP at any time. Simply create a Blue Cross Blue Shield of Massachusetts account or sign in to MyBlue to select your PCP online, or call their Member Service line at the number on the front of your ID card

Your doctor may request an exception from our Clinical Pharmacy Department to provide coverage for a non-covered drug when medically necessary. If approved, the drug will require the highest copayment level. If the request is not approved, you will remain responsible for the full cost of the prescription. You may use our standard member appeals process to request further review.

New ID cards are issued whenever benefits change. This might be the result of your employer's decision or a change in Massachusetts law. Your ID card contains valuable information, including phone numbers and copayment amounts, so be sure to read both sides carefully. Always carry your ID card with you to show your pharmacist or doctor.

Drugs generally require prior authorization in cases where the patient must meet certain medical-necessity criteria. For certain drugs approved by the Food and Drug Administration (FDA) and included on our covered drug list, we require the physician to obtain prior authorization before we reimburse the cost of the prescription drug. These drugs are listed in the formulary search. Patients must have pharmacy benefits under their subscriber certificates that cover those drugs that require prior authorization. Please see your plan sponsor for details.

On an ongoing basis our Pharmacy & Therapeutics Committee reviews the safety, effectiveness, and overall value of new drugs approved by the FDA. While a new drug is being reviewed, it will not be covered by your plan. This policy will not apply to members of our Medex®’ and Medicare HMO Blue® plans. As with other non-covered drugs, your physician may request coverage for a drug under review when medically necessary.

Blue Cross Blue Shield of Massachusetts relies on physicians practicing in Massachusetts to provide feedback on pharmacy program decisions. This committee, made up of representatives of physician organizations in Massachusetts, reviews drug comparisons for clinical benefit, side effects, and relative cost. The principle mission of the committee is to ensure that our members have drugs covered, or made available on an exception basis, that meet their needs and achieve desired treatment goals.

To check if a certain drug is under review and not yet covered, call the Member Service number on the front of your ID card.

PBMs, like the one we've partnered with, Express Scripts, Inc., are companies that specialize in administering prescription drug benefit programs. They also maintain an extensive retail pharmacy network to process your prescriptions. Because of their size, PBMs can negotiate discounted prices from drug companies.

Over the last two decades, the use of prescription drugs to treat illnesses ranging from allergies to heart disease has increased dramatically. With this development came greater demand for brand-name medications.

During the same period, legislation has allowed drug companies to extend their patents on brand-name drugs, which allows the drugmaker to sell the drug exclusively for many years with limited competition.

Drug advertising regulations have loosened as well, spurring expensive marketing campaigns for brand-name drugs. These television and magazine ads have raised people's awareness of new drugs, resulting in a rapid increase in the number of requests for expensive, brand-name prescriptions.

No. Generic and brand-name drugs must meet the same FDA standards for safety, purity, strength, and effectiveness. The generic name of a drug is its chemical name. The brand name is the trade name under which the drug is advertised and sold. In general, generic drugs will save you money. So whenever possible, ask your doctor to prescribe generic drugs.

If you take medications on a regular basis, mail order pharmacy is a convenient way to save time and money. For most plans, you can order up to a 90-day supply through the mail, usually for the same amount you would pay for a 30-day supply at your local pharmacy. Plus, you can receive your medications through the mail, at home, or at work, postage paid, within 14 days of mailing your prescription.

In general, it's a good idea to plan ahead so that you don't have to worry about running out of your medications while on vacation. The first step is to get a prescription from your doctor for the amount of the medication needed.

If you're traveling within the U.S. and anticipate that your prescription will run out, ask your doctor for another prescription to take with you. You can fill your prescription at any participating pharmacy in the U.S. Our network consists of 94 percent of the pharmacies nationwide, including most major chains. To find a participating pharmacy in the area in which you'll be traveling, call Express Scripts Customer Service at 1-800-892-5119.

If you are traveling out of the country, your pharmacist will know how to obtain authorization for a special supply.

Yes. If you have a drug benefit you can fill your prescription at any participating pharmacy nationwide. Our network consists of 94 percent of the pharmacies nationwide, including most major chains. You can call the phone number on the front of your ID card to find a participating pharmacy near you.

Though you should always speak with your physician or pharmacist if you have any questions about prescription drugs, the Drug Search tool at ahealthyme.com can give you instant, up-to-date information on more than 4,000 prescription and over-the-counter drugs, including their interactions and side effects.

A formulary is a list of drugs covered by a health plan. Ours contains more than 3,500 drugs. It was developed by doctors and pharmacists after careful evaluation of clinical studies to determine which medications are most effective, safe, and maximize cost savings. Most plans, like ours, also maintain a small list of non-preferred drugs. The vast majority of the non-preferred drugs have one or more FDA-approved, covered alternatives. Our formulary allows us to offer you brand-name and generic drugs that meet your needs at a reasonable cost.

Quality Care Dosing (QCD) is a program designed to ensure that the quality and dose of your prescription for certain medications meet FDA and other accepted clinical practice guidelines. In cases where it doesn't, QCD offers modifications to bring quantity and dosage in-line with FDA recommendations.

If you have more than one medical or dental insurance plan you are required to provide this information to each insurer and your providers so your claims can be processed correctly, and you can get the most out of your coverage.

When you have more than one insurance plan, one plan is designated as your primary plan and will pay your claims first. The other plan(s) will pay toward the remaining cost, according to your benefits. Federal and state rules typically determine which plan is primary. If you have a question about Coordination of Benefits, please call 1-888-799-1888. Or click to learn more.

Yes. You may change your PCP at any time and as often as you choose. You do not have to specify a reason. Your change is effective immediately upon notifying us.

If you are an HMO Blue, HMO Blue New England, Blue Choice, or Blue Choice New England member, you must choose a PCP. Your PCP is your partner in guiding you through the health care system. In addition, your PCP will serve as your health care advisor when you have questions or need treatment, and will make sure you receive the care you need.

Choosing your PCP is important, and there are several factors you should consider when making your decision. You might want a PCP with a particular subspecialty, such as gastroenterology or cardiology, or perhaps you want a PCP who is affiliated with a particular hospital. You might be more concerned with your PCP's education, or maybe location or public transportation access matters to you most. Before choosing a PCP, make a list of the things that are most important to you. Then you can find a PCP in one of three ways:

• Use our Find a Doctor & Estimate Costs service and create your own Provider Directory.
• You can obtain a Provider Directory for your plan by calling 1-800-262-BLUE (2583).
• You can also call our Find a Doctor Support Line at 1-800-821-1388 if you'd like help selecting a PCP.
• Once you select a PCP, create an account or sign in to MyBlue to designate your PCP, or call Member Service at the number on the front of your ID card.

If you are an HMO Blue member and receive services without choosing a PCP, those services will not be covered. A PCP must be noted for services to be covered and paid. If you are a Blue Choice member, you should have a PCP on our records, even though you may wish to see providers who are not in the network. Please note that Blue Choice members incur higher out-of-pocket expenses when they self-refer.

Yes. Each member of your family should choose a PCP who best suits their needs. Our New England plans include PCPs in all six New England states.

Yes. All HMO Blue^® and HMO Blue New England^SM members must get a PCP referral before seeing a specialist. Because your PCP knows your history and health care needs, he or she is best qualified to help you decide whether a specialist is needed. Blue Choice® and Blue Choice New England^SM members have the option to self-refer for covered services at a higher out-of-pocket cost.

Always discuss your concerns with your PCP. Your PCP will work with you to explore all the available options and make sure your medical needs are met.

Blue Cross and Blue Shield does not offer incentives to limit your care. That means your PCP concentrates on making sure you receive appropriate care in the right setting.

As a general rule, Blue Cross Blue Shield of Massachusetts will not pay for care from a specialist without a referral from your PCP. However, the following are instances when you do not need a referral:

• Emergency care.
• For HMO Blue and Blue Choice members, covered services from a network obstetrician, gynecologist, or certified nurse midwife, or gynecological services and other women's health services from a network family practitioner.
• A routine eye exam every two years for HMO Blue New England and Blue Choice New England members.
• An annual routine eye exam for HMO Blue and Blue Choice members.

 
Blue Choice members have the option to self-refer at a higher level of out-of-pocket costs for any other covered service. Create an account or sign in to MyBlue to review your benefits.

The cancer care team that orders your outpatient medical oncology treatment (like chemotherapy, immunotherapy, and certain medications), or radiation oncology treatment, will need to request prior authorization for coverage. This helps us ensure that you're getting the most clinically appropriate and evidence-based cancer treatment, with minimal side effects.

To learn more, read our fact sheet.

While your plan covers most types of treatment, there may be some exceptions based on the specifics of your plan. For example, if your plan doesn't cover prescription drugs, you'll be responsible for paying for those your doctor prescribes. Additionally, some treatments and services, such as genetic testing, outpatient medical oncology and outpatient radiation oncology treatment, require prior authorization for coverage. Doctors who order these types of treatments should request prior authorization for you. Be sure to read your subscriber certificate carefully to find out what is covered and what may be excluded.

Based on the type of plan that a member has and the design of their plan, colonoscopies can process under one of two benefits. The cost of the service could fall under their Surgery as an Outpatient benefit or their Routine Adult Physical benefit. The liability is determined by the procedure(s) performed as well as the outcome or diagnosis determined at the visit.

If you think you need to see a specialist, you should discuss it with your PCP. Your PCP will help you determine whether or not a specialist is needed and refer you to one who is best qualified to treat your condition.

The network includes a comprehensive listing of doctors in a wide variety of specialties. If your doctor believes you need to see a type of specialist not included in the network, he or she may refer you to one outside the network and those services will be covered.

If you are an HMO Blue member you will need a PCP referral for services except for visits to your PCP, covered services from a network obstetrician, gynecologist, certified nurse midwife, gynecological services and other routine women's health services from a network family practitioner, and hearing and vision exams (once yearly for HMO Blue and Blue Choice members, once every 24 months for New England plan members).

Finding a doctor is easy and can be done in one of three ways:

• Use our Find a Doctor & Estimate Costs service and create your own Provider Directory.
• You can obtain a Provider Directory for your plan by calling 1-800-262-BLUE (2583).
• You can also call our Find a Doctor Support Line at 1-800-821-1388 if you'd like help selecting a PCP.
• Once you select a PCP, create an account or sign in to MyBlue to designate your PCP, or call Member Service at the number on the front of your ID card

Your first step is to call Member Service at the number on the front of your ID card. Our representatives are trained to help resolve any problems or concerns you may be having.

Your most recent Explanation of Benefits shows deductible amounts met for the current year. You can also call Member Service at the number on the front of your ID card.

Most of our plans cover routine physical exams and immunizations. Check your benefit literature or call Member Service at the  number on the front of your ID card for information about your specific plan.

If you need emergency medical attention, go to the nearest medical facility or call 911 (or the local emergency number). If your medical need is not an emergency, please call Member Service at the number on the front of your ID card

You'll be happy to know that maternity benefits are part of nearly every plan we offer. Your subscriber certificate will tell you what services are covered. Some plans also require that you call to notify us of an expected maternity admission in advance, while others do not have this requirement.

New parents sometimes forget to update their Blue Cross Blue Shield of Massachusetts membership records when a baby is born so that claims will be paid according to your plan benefits without delay.

And don't forget, Living Healthy Babies® is always available when you need it, providing answers to baby questions from parents and parents-to-be.

Yes. Lab tests, X-rays, and other medical tests are covered when ordered by your physician. Coverage will vary from plan to plan. Check your subscriber certificate for details.

Your doctor must get prior authorization from us before we’ll cover certain genetic tests. This helps us make sure that you're getting the right test, and that it's covered by your health plan. If your doctor doesn’t get prior authorization, you’ll be responsible for the full cost of certain genetic tests. The following genetic testing categories require prior authorization:

• Prenatal screening and diagnosis of specific conditions
• Genetic/DNA testing of hereditary cancer risks
• Testing to detect DNA changes associated with specific diseases or conditions
• DNA sequencing
• Pharmaceutical testing to identify medicine and dosing requirements
• Genetic/DNA testing of hereditary heart disease risks
• Genetic/DNA testing of tumor cells

To learn more about these procedures, read our fact sheet or visit ahealthyme.com.

No. Marriage blood tests are not "medically necessary" and are not covered.

Exams required to participate in school, sports, camp, etc., are not covered. However, routine physical exams are, according to an age-based schedule. See your subscriber certificate for details.

For children under age 12, HMO Blue and Blue Choice covers preventive dental care when provided by a Blue Cross Blue Shield of Massachusetts participating dentist. This includes one initial exam per child, followed by one periodic exam every six months, one cleaning every six months, one fluoride treatment every six months and bitewing X-rays every six months. (HMO Blue New England, Blue Choice New England, Blue Care Elect, and our indemnity products do not cover this benefit.)

We also offer separate dental coverage through our Dental Blue^® and Dental Blue PPO plans. Create an account or log in to review your dental benefits.

HMO Blue New England and Blue Choice New England include chiropractic coverage as part of their benefit plans. For other products, you must have a "Chiropractic Rider" in order for you to have chiropractic coverage.

As a result of the health care reform law in Massachusetts, changes have been made that affect dependent eligibility.

For more information, visit Health Care Reform.

Our HMO Blue, Blue Choice, and Blue Care Elect Preferred^SM plans include coverage for one routine eye exam per calendar year. Our HMO Blue New England and Blue Choice New England plans include coverage for one routine eye exam every 24 months as long as you see a network provider.

In an emergency situation, call 911 (or your local emergency number) or go to the nearest medical facility.

Medical policies are scientific documents that define the technologies, procedures and treatments that are considered investigational, medically necessary, and not medically necessary. Medical policy statements contain conclusions about whether a technology, procedure, treatment, supply, equipment, drug or other service improves health outcomes for the health plan's population and therefore is covered or not covered.

Learn more about medical policies.

When you and your primary care provider (PCP) determine that you need specialized care, your PCP will "refer" you to a specialized provider from our trusted team. A referral is required by your HMO health plan before the plan will cover certain services. It’s important that the referral comes from us—not only because your plan requires it, but because your PCP, as the center of your care, needs to be involved and aware of the care you’re receiving, and to coordinate with you and your specialist on an ongoing basis.

Your PCP knows your history and overall health, so he or she is best qualified to help you decide if you should see a specialist. Even if your health plan doesn’t require a referral, your PCP may want to evaluate your care needs before you see a specialist, in order to better coordinate your care. We’re committed to making sure you get the right care, at the right time, in the right setting—especially if you need to see a specialist.

Contact your PCP’s office to discuss your health situation. Together, you can decide if you need to see a specialist. If you do need to visit a specialist, your PCP will help you choose the most appropriate doctor for the care you need. Be sure to have this conversation before you visit a specialist. If you see a specialist without a referral, you may be responsible for the entire bill (not just the copay or deductible).

We rely on a trusted network that includes a wide range of specialists to carry out your treatment plan. By referring you to specialists we know well, you, your specialist, and our group can work together to ensure you get high-quality, timely, and effective care.

Please note that not all of the specialists in your health plan’s network are a part of our group. It’s very important to always discuss your clinical condition and concerns with your PCP to determine together if a specialist visit is needed and which doctor is best for you.

Because your PCP coordinates your care, you should always let our group know whenever you seek treatment of any kind. There are certain instances, however, when you don’t need a referral from your PCP in order to receive coverage from your health plan, including cases when you seek emergency medical care, covered annual gynecological exams, and other services required as result. For further details about the specific cases that don’t require a referral, please call Member Service at the number on the front of your ID card.

As the coordinator of your care, you should always contact your selected PCP about your emergency room visit. He or she will determine the best coordinated follow-up care for you.

There are several ways to learn about your plan's referral requirements: check your subscriber certificate provided by your health plan or call Member Service at the number on the front of your ID card. It's essential that you fully understand your plan's referral requirements, because if you don't get a required referral prior to receiving non-emergency care, you may be responsible for the entire bill (not just a copayment or deductible).

If you have a medical question about a referral, just call us. If you need information about whether a service is covered or requires a referral by your health plan, please call Blue Cross Blue Shield of Massachusetts’s Member Service at the number on the front of your ID card.

As a general rule, Blue Cross Blue Shield of Massachusetts will not pay for care from a specialist without a referral from your PCP. However, the following are instances when you do not need a referral:

• Emergency care.
• For HMO Blue and Blue Choice members, covered services from a network obstetrician, gynecologist, or certified nurse midwife, or gynecological services and other women's health services from a network family practitioner.
• A routine eye exam every two years for HMO Blue New England and Blue Choice New England members.
• An annual routine eye exam for HMO Blue and Blue Choice members.
• Blue Choice members have the option to self-refer at a higher level of out-of-pocket costs for any other covered service.

Your Subscriber Claim Summary explains how we processed a claim. It is not a bill, and you should not send any payment to us (if there is a balance listed, the health care provider will notify you of your responsibility).

The Subscriber Claim Summary includes the name of the health care provider who sent us the claim, the date of service, the type of service (lab, surgery, medical care, etc.) and the amount the provider charged for the service. It also includes any deductible, copayment, or co-insurance that applies, and any patient balance. Deductibles, copayments, or co-insurance are included on some health plans, and simply indicate how much you share in the cost of health care.

If you have questions about the services rendered, you should contact the health care provider. If you have questions about how any patient balance was determined, you can create an account or login to view your account or check your member literature to determine coverage, including any applicable deductible, copayment, or co-insurance that might apply. If you have questions, please contact Member Service at the number on the front of your ID card.

It's important to carry your ID card with you at all times. Your Blue Cross Blue Shield of Massachusetts card is recognized around the world. If you lose your card and need a replacement, simply create an account or sign in to MyBlue to request a new card online, or call Member Service. If you have a family plan, and have access to another family member's ID card, please call the Member Service number shown on the front of the card. If you do not have access to another family member's card, you should call 1-800-462-5601.

Making changes to your membership is simple. If you have your coverage through your employer, simply contact your employer's benefits office to complete the appropriate form. If you have direct-payment coverage (e.g., Access BlueSM Saver II, HMO Blue® Basic Value), call Member Service at the toll-free number on the front of your ID card. We'll send you a form to complete and return. For all of our standard plans, we must receive notification within 30 days of the qualifying event.

As a result of the health care reform law in Massachusetts, changes have been made that affect dependent eligibility.

For more information, visit Health Care Reform.

If your child is approaching adulthood, it may be time to speak with them and their pediatrician about transitioning to a doctor with a focus in Adult, Family, or Internal Medicine.

If it's time for a new doctor, we can help! Check out our Find a Doctor & Estimate Costs tool to search hundreds of doctors and find the best one for your young adult.

When you receive a bill from your doctor, it is often for your copayment, co-insurance, or deductible. These are features of health plans, and basically have the member share in some of the cost of their health care. For example, some health plans require that the member pay $10 for an office visit and the rest is covered by the plan.

If you have additional questions, please call Member Service at the number on the front of your ID card. Be sure to have your ID number, health care provider's name, and the date of service handy when you call.

Since all network specialists can verify if you have a referral electronically, you should not be asked if you obtained a referral. If you are ever asked, you should advise the specialist to check electronically or they can call Member Service at the number on the front of your ID card, and our Provider Services staff will assist them.

If you have a managed care plan (like HMO Blue or Blue Choice®), your primary care provider (PCP) provides or arranges for most of the care you need. If you require the care of a specialist, in most cases you must obtain a referral from your PCP to receive coverage.

Create an account or sign in to MyBlue to review your Summary of Benefits or check your benefit materials (In most cases, this is called either the Member Handbook, Subscriber Certificate, or the Summary Plan Description.) Materials are organized in general categories like inpatient care, outpatient care, surgery, medical equipment, prescription drugs, etc. Virtually all questions can be answered with a quick check of your benefit materials.

If you have additional questions or concerns, please contact Member Service at the number on the front of your ID card. When you call, it is important for you to know the specific type of service involved so that a representative can help you.

Everyone has different priorities, and therefore their needs in a health plan can differ. However, here are some key elements that most everyone would find important in the benefits of a health plan:

• Does the provider network include your physician and hospital?
• Can your physician make referrals to specialists without first checking in with the health plan?
• Is the health plan recognized across the country and around the world?
• Does the health plan cover the services you are interested in receiving?
• Does the health plan have convenient customer service hours?
• What are the special features of being a member (for example, health club reimbursement and discounts on complementary medicine services)?

People sometimes have insurance coverage under more than one health plan, so we periodically send a survey to our members asking them if they have other coverage. This is to ensure that claims are processed correctly and that overpayments are not made. We see significant cost savings by coordinating payments with other insurers—savings that ultimately result in more affordable premiums for our members.

When you receive a survey, it's important that you complete and return it so that we have the most up-to-date information and can process your claims correctly. We make it easy for you to reply by providing postage-paid return envelopes and 24-hour telephone reply options.

We regularly survey a random sample of our members to determine how satisfied they are with the coverage and services we provide. By listening to this feedback, we have taken steps to bring satisfaction to world-class levels. If you do receive a survey, please complete and return it. Your participation is critical to the direction we take on coverage and service issues.

We don't expect that you will ever have a concern, but if you do, most issues can be handled with just one phone call. For help resolving a problem or concern, please first call Member Service at the toll-free number on the front of your ID card. A Member Service representative will work with you to help you understand your coverage and resolve your problem or concern as quickly as possible. If you disagree with the resolution provided by the Member Service representative, you may request a review through our formal Appeal and Grievance Program.

Please contact your Human Resources department to ensure that they have your new address on file. Periodically, your employer will submit updated enrollment information to Blue Cross Blue Shield of Massachusetts. If your Human Resources department has your old address on file, your new address may be overwritten.

The Massachusetts Department of Revenue (DOR) requires health insurance companies and/or employers to provide subscribers with the 1099-HC form to help Massachusetts residents complete their 2019 state tax filings.

1099-HC forms will be issued to subscribers of Blue Cross Blue Shield of Massachusetts and will list spouse and dependent information. Students who are dependents on a parent's insurance plan will need information contained on the 1099-HC form to complete their income tax returns.

Your 1099-HC form indicates whether you had minimum creditable coverage (MCC) for each month in the preceding year. A month with coverage is defined as a month in which the individual was covered for 15 days. If the individual had coverage for 14 days or less in a month, it is considered a month without coverage.

If you had health insurance with multiple insurance carriers, you may receive multiple Form 1099-HC. Your Form 1099-HC, which you'll receive from Blue Cross via mail and your MyBlue account, will indicate which months in 2019 you had a Blue Cross Blue Shield of Massachusetts health insurance policy. If you had health insurance through another carrier, you may receive separate Form1099-HC from them. If you were insured through Blue Cross Blue Shield of Massachusetts for all 12 months of the tax year, the "Full Year Coverage" box is checked off. If you were insured through Blue Cross Blue Shield of Massachusetts for less than 12 months, only those months that you or a dependent on your policy had 15 or more days of health insurance in a given month have a check in the appropriate month's box.

Please visit Massachusetts Department of Revenue for more information regarding penalties. Blue Cross Blue Shield of Massachusetts is not involved in this process.

We use our enrollment records to determine the months in which you had Blue Cross Blue Shield of Massachusetts coverage for 15 days or more. This is consistent with Massachusetts Department of Revenue Schedule HC instructions.

Forms 1099-HC were mailed to Blue Cross Blue Shield of Massachusetts subscribers who live in Massachusetts and were enrolled in a health plan at some point in 2019. Please refer to your 2019 tax filing information, your tax preparation advisor, or visit the Massachusetts Department of Revenue for information about using the information contained in the Form 1099-HC to complete your state tax filing.

All 1099-HC forms to eligible subscribers will be:

• Posted online to your MyBlue account on January 31, 2020
• Postmarked for mailing by January 31, 2020

If you haven't received a form by the first week of February 2020, and you can't access it on MyBlue, please call Member Service using the number on the front of your ID card.

Please note that not all members will receive a 1099-HC form from Blue Cross Blue Shield of Massachusetts. You won't receive a form if you:

• You're a subscriber younger than 18 years of age
• You have a dental-only or vision-only plan through Blue Cross Blue Shield of Massachusetts
• You're a member of one of our Medex®' or Medicare Advantage plans

If you still have questions about whether you're eligible or excluded, please refer to your tax advisor or the Massachusetts Department of Revenue or call 1-800-392-6089.

No. Individuals with Medicare supplemental insurance or replacement plans won't receive a Form 1099-HC.

If you turned 18 during 2019, the health care mandate applies to you beginning on the first day of the first full month following your birthday. For example, if your birthday is June 15, the mandate applies on July 1.

Yes. Qualified subscribers can download a PDF version of their Form 1099-HC from their MyBlue account.

The form will be added on January 31, 2020. Go here to see your tax form on or after this date

All forms were mailed by January 31, 2020. If there is an alternate address on the policy, the 1099-HC form will be mailed to the alternate address. If you still haven't received a form by the first week of February 2020, please call Member Service using the number on the front of your member ID card to request one.

You may also be eligible to view your Form 1099-HC online. To do so, sign in to MyBlue and view your Tax forms on or after January 31, 2020

You must first request an alternate address through our System Security process before we can send a 1099-HC form to that address. For assistance, please call Member Service at the number on the front of your ID card.

1099-HC form mailings are staggered throughout the month of January based on ZIP codes, and all forms to eligible subscribers will be postmarked by January 31, 2020. If you don't receive your form by the first week of February, please call Member Service using the number on your ID card.

Not necessarily. Due to the setup of the 1099-HC form, member numbers may appear differently than on your member ID card. Member numbers on the 1099-HC form don't include the member suffix, and will contain additional zeros at the end of your member number. The 1099-HC form will list the subscriber's member number first followed by the subscriber's dependents, which will be listed by date of birth (oldest to youngest).

No. Subscribers can photocopy the form for the dependents.

Please contact the Health Care Connector or the Massachusetts Department of Revenue.