Product Disclosures

All product disclosures are applicable to all Plans underwritten by BCS Insurance Company and 4 Ever Life Insurance Company.

For all Plans underwritten by 4 Ever Life Insurance Company only:

For Medical Policies and Guidelines, go to: https://www.amerihealth.com/providers/policies_guidelines/medical_policy.html

The applicable Medical/Surgical and Mental Health/Substance Use Disorder Guidelines, are available by clicking on these links:
For M/S guidelines, Medical Necessity Policy 12.01.02a: AmeriHealth Medical Policies
For MH/SUD guidelines, see Magellan Care Guidelines: Magellan Care Guidelines 2022-2023 (magellanprovider.com)

Product Disclosures – Applicable to all EssentialCare Fixed Indemnity and EssentialCare Hospital Indemnity products

IMPORTANT: This is a fixed indemnity policy, NOT health insurance.

This fixed indemnity policy may pay you a limited dollar amount if you’re sick or hospitalized. You’re still responsible for paying the cost of your care.

• The payment you get isn’t based on the size of your medical bill.
• There might be a limit on how much this policy will pay each year.
• This policy isn’t a substitute for comprehensive health insurance.
• Since this policy isn’t health insurance, it doesn’t have to include most Federal consumer protections that apply to health insurance.

Looking for comprehensive health insurance?

• Visit HealthCare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325) to find health coverage options.
• To find out if you can get health insurance through your job, or a family member’s job, contact the employer.

Questions about this policy?

• For questions or complaints about this policy, contact your State Department of Insurance. Find their number on the National Association of Insurance Commissioners’ website (naic.org) under “Insurance Departments.”
• If you have this policy through your job, or a family member’s job, contact the employer.

Product Disclosures – Applicable to all GeoBlue^® Plans (NOTE: these do not apply to all Plans)

GeoBlue Language Assistance program and Notice of Additional Services for hearing and visually impaired individuals (PDF)

Telecommunication Relay Service (TRS) for the hearing or speech impaired (PDF)

GeoBlue Non-Discrimination Notice (PDF)

Grievance & Appeals:
Notice of Appeal Rights to Connecticut Residents (PDF)

GeoBlue Prescription Benefits

Retail Pharmacy & Mail Order Prescription Benefits
Not all members have access to all prescription drug services. Review your Certificate of Insurance for benefits.

Prescription benefit coverage provided under the plan includes benefits for both retail pharmacies as well as two mail order prescription drug programs. One mail order prescription drug program is designed for members residing in the United States. The second mail order prescription drug program is designed for members residing overseas. For a full list of covered and non-covered services, see your Certificate of Insurance.

Retail Pharmacies
Members have access to over 44,000 participating pharmacies within the United States. Members are responsible for paying 100% of the co-payment at retail pharmacies or members may file a claim for reimbursement for purchases made at retail pharmacies. For reimbursements, simply complete a Prescription Claim Form and submit directly to the claims administrator, GeoBlue for reimbursement.

Drug Formulary Guide (PDF)

Mail Order Program if Residing in the United States
Provided by Elixir Pharmacy.
Online: Visit the website here
Phone: Call Elixir Pharmacy at 1-888-773-6380, U.S
Hours: Elixir Pharmacy Customer Care Representatives and Clinical Pharmacists are available 24 hours daily.

To submit prescriptions, prescribers can reach Elixir Pharmacy by:
E-Prescribe or EDI Number NCPDP 36-77361
Phone: 1-888-773-6380 U.S.
FAX: 1-866-909-5171

Or prescriptions can be mailed to:
Elixir Pharmacy
7835 Freedom Ave NW
North Canton, OH 44720
To enroll in the mail order program, you can call the above number or you can enroll online here. Once you’ve establish an account, you can log into your profile to reorder medications or place new orders.

Mail Order Program if Residing Outside the United States
Provided by Expatriate Prescription Services (EPS). Expatriate Prescription Services (EPS) has a licensed pharmacy staff with a wealth of experience delivering medications to over 160 countries.

To place an order, you can call EPS at the below number or complete the online order form at www.expatps.com. Submit your prescription details via email to [email protected] or fax your prescription(s) to 540-777-7184.

Online: www.expatps.com
Phone: call an EPS Representative to order outside of the U.S. at 540-777-1450; hours: 8:30am – 5:00pm EST, U.S.
Fax: 540-777-7184.
Email: Email a copy of your prescription(s) to [email protected].
If you choose to use a pharmacy outside of this program, or if EPS is unable to ship to your location, you must pay out of pocket and submit a claim form for reimbursement. For reimbursements, complete a Prescription Claim Form and submit directly to the claims administrator, GeoBlue, for reimbursement. If you need assistance in locating a pharmacy while outside of the U.S. call GeoBlue toll-free in the U.S.1.855.282.3517; collect from outside the U.S. 1.610.254.5304; or email [email protected].

Questions?
If you have questions regarding your benefits or the information in your certificate, contact GeoBlue for more information.
Phone: +1 610.254.5304 (Collect Calls Accepted) or +1 855.282.3517 (U.S. Toll Free)
Email: [email protected]; someone will respond on the next business day.

Product Disclosures by State

Connecticut

Anthem Blue Cross Blue Shield of Connecticut

Network Adequacy and Accessibility
While in Connecticut, GeoBlue members have access to Anthem Blue Cross Blue Shield of Connecticut’s network of doctors, hospitals and facilities throughout the state via the BlueCard® Program. To review Frequently Asked Questions about their network, please click on the link Anthem Blue Cross Blue Shield of Connecticut FAQs

To review how Anthem Blue Cross Blue Shield of Connecticut chooses providers and facilities for their network, please see this document available on Anthem’s website describing the criteria used to build their network, including quality of care, the member experience, accessibility and cost.
Anthem Blue Cross Blue Shield of Connecticut Doctor/Facility Selection Criteria (PDF)
Anthem Blue Cross Blue Shield of Connecticut/Search Providers

For more detailed information regarding the Network’s Policies and Procedures on Credentialing and Recredentialing, please visit Anthem’s website at https://www.anthem.com/provider/credentialing

Provider Access Notice
You may select primary and specialty providers via electronic access using the provider search tool known as Find-a-Doc. Log on to www.geo-blue.com anytime you’re on the web to browse our online provider directory or directly link to the Blue National Doctor and Hospital Finder, which is updated weekly. You can search by languages spoken, specialty, hospital association, and more. Additionally, you can request a copy of the provider directory through a toll-free number (1-855-282-3517).

When you need medical attention when you’re traveling, or if you live in another Blue Cross Blue Shield area, you can get a list of doctors and hospitals across or outside the U.S. by calling 1-800-810-BLUE (2583), or by visiting the Blue National Doctor and Hospital Finder.

Service Area
In the event that you cannot find a primary or specialty provider without unreasonable travel or delay from your Connecticut residence, or if the services is not available through a Participating Provider, Covered Expenses for the services of a Non-Participating Provider will be paid according to the in-network benefit schedule. Please call Customer Service at 1-855-282-3517 to notify us in advance, so we can ensure that the claim is processed correctly. In the event the claim is not processed correctly, please contact customer service to inform us and we will adjust the claim accordingly.

Pharmacy Availability & Accessibility Table
Individuals enrolled in a Blue Cross Blue Shield Global Expat plan have access to a pharmacy network while residing in or visiting Connecticut. The adequacy of the pharmacy network in terms of the number of pharmacies and the time in minutes and distance in miles for current insured residents of Connecticut is shown by county in this pharmacy time and distance table (PDF).

CT Formulary: CT Formulary PDF
NOTE: This is a CT specific Formulary for CT members only and the search tool will not apply to CT members.

Minnesota

Provider Networks
For any GeoBlue members in Minnesota, GeoBlue members have access to a large network of medical providers in Minnesota established by Blue Cross Blue Shield of Minnesota and available to GeoBlue members insured under a Blue Cross Blue Shield Global product through the BlueCard® program. For a list of providers, which is updated at least monthly, please go to Blue Cross Blue Shield Provider Finder.

Although we strive to have a broad network available to you, if you live in Minnesota and you are unable to find a primary care physician, mental health services or general hospital services within 30 miles or 30 minutes of your residence, or for other health services within 60 miles or 60 minutes, you are eligible to have your out-of-network services paid at the in-network rate.

In the event a network provider is not accessible, please Contact Customer Service at 1.888.412.6403 or +1.610.254.5830, or by email at [email protected], to let them know and to ensure that your claims, when submitted, will be paid at the in-network rate.

Texas

4 Ever Life provides health benefit services to all TX covered insureds using the BCBS of TX Blue Choice PPO Network. We are herewith providing a copy of the 2022 Provider Directories. You may also access the BCBS of TX website through www.bcbstx.com for the most updated list of Blue Choice PPO participating doctors and hospitals, which are updated on a monthly basis.  

PDF links: Abilene-San Angelo | Amarillo | Austin-1 | Austin-2 | Austin-3 | Beaumont | Corpus Christi | Dallas-1 | Dallas-2 | Dallas-3 | El Paso | Fort Worth-1 | Fort Worth-2 | Houston-1 | Houston-2 | Houston-3 | Houston-4 | Lubbock | Midland-Odessa | San Antonio-1 | San Antonio-2 | The Valley | Tyler-Texarkana-1 | Tyler-Texarkana-2

You have the right to an adequate network of preferred providers (also known as “Blue Choice PPO Network”). If you believe that the network is inadequate, you may file a complaint with the Texas Department of Insurance.

You have the right, in most cases, to obtain estimates in advance:
– from out-of-network providers of what they will charge for their services; and
– from your insurer of what it will pay for the services.

You may obtain a current directory of preferred providers at the following website: www.geo-blue.com or by calling Customer Service at 1.888.412.6403 or +1.610.254.5830 or by email at [email protected] for assistance in finding available preferred providers.

If you are treated by a provider or facility that is not a preferred provider, you may be billed for anything not paid by the insurer.

If the amount you owe to an out‐of‐network hospital‐based radiologist, anesthesiologist, pathologist, emergency department physician, neonatologist, or assistant surgeon, including the amount unpaid by the administrator or insurer, is greater than $500 (not including your copayment, coinsurance, and deductible responsibilities) for services received in a network hospital, you may be entitled to have the parties participate in a teleconference, and, if the result is not to your satisfaction, in a mandatory mediation at no cost to you. You can learn more about mediation at the Texas Department of Insurance website: www.tdi.texas.gov/consumer/cpmmediation.html.

If directory information is materially inaccurate and you rely on it, you may be entitled to have an out-of-network claim paid at the in‐network percentage level of reimbursement and your out-of-pocket expenses counted toward your in‐network deductible and out‐of‐pocket maximum.

Telehealth Medical Service and Telemedicine Medical Services for Texas based Group Plans
In accordance with Chapter 1455 of the Texas Insurance Code, Blue Cross Blue Shield Global Expatriate Health plans provides benefits for covered services that are appropriately provided through Telehealth Medical Service and Telemedicine Medical Services, subject to the terms and conditions of the Plan. In-person contact between a health care Provider and the patient is not required for these services, and the type of setting where these services are provided is not limited. Telehealth Medical Service and Telemedicine Medical Services does not include consultations between the patient and the health care Provider, or between health care Providers, by telephone, facsimile machine, or electronic mail.

Equipment costs and transmission costs associated with Telehealth Medical Service and Telemedicine Medical Services are not reimbursable.

The Pre-Authorization Procedural Guidelines are available by clicking here: GeoBlue | Procedural Guidelines (geo-blue.com)

Customer Service

Need additional assistance with GeoBlue product?
Contact Customer Service at 1.888.412.6403 or +1.610.254.5830, or by email at [email protected].

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