Product Disclosures – Applicable to all Plans

For Medical Policies and Guidelines, go to: https://www.amerihealth.com/providers/policies_guidelines/medical_policy.html
Notice of Nondiscrimination (PDF)
Language Assistance Service (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

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 eps@universalrx.com 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 eps@universalrx.com.
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 globalhealth@geo-blue.com.

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: customerservice@geo-blue.com; 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 below 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
Anthem Blue Cross Blue Shield of Connecticut/How we choose doctors and hospitals for our plans (PDF)

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 1.888.412.6403 to notify us in advance, so we can ensure 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.

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.

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 customerservice@geo-blue.com, to let them know and to ensure that your claims, when submitted, will be paid at the in-network rate.

Texas

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 customerservice@geo-blue.com 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.

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 customerservice@geo-blue.com.


Florida Mental Health Parity Notice

What are Your Rights Under the Mental Health Parity Laws?
Your health coverage is subject to state and federal Mental Health Parity laws, which generally prohibit insurance plans from providing mental health or substance use disorder benefits in a manner that is no more restrictive than other medical benefits. If you believe our standards or practices relating to the provision of mental health or substance use disorder benefits are not compliant with the mental health parity laws, you, or your authorized representative, may submit a complaint to the Division of Consumer Services at:

FDACS-Division of Consumer Services
P. O. Box 6700
Tallahassee, FL 32399-6700
1-800-HELP-FLA (435-7352) for English
1-800-FL-AYUDA (352-983) for Spanish

Complaint Hyperlink for English:
https://csapp.fdacs.gov/CSPublicApp/Complaints/FileComplaint.aspx

Complaint Hyperlink for Spanish:
https://csapp.fdacs.gov/CSPublicApp/Complaints/FileComplaintSpanish.aspx

For more information on mental health benefits, please refer to your Certificate of Coverage/Schedule of Benefits or call the toll-free number on your Health ID Card.

Mental Health Parity and Addiction Equity Act (MHPAEA)

All small group, large group, and individual plans, on and off-exchange, are required to be compliant with the following MHPAEA standards or requirements for Mental Health and Substance Use Disorder Services (MH/SUD).

MH/SUD Requirement:

Defining MH/SUD Benefits

Reference:
42 U.S.C. 399gg-26
42 U.S.C. 18031 (j)
45 CFR 146.136 (a)
45 CFR 156.115 (a) (3)

Description of Standards or Requirements:
The plan shall define mental health benefits or substance use disorder benefits to mean items or services for the treatment of a mental health condition or substance use disorder, as defined by the policy or contract or applicable state law. Any condition or disorder defined as not a mental health condition or substance use disorder must be consistent with generally recognized independent standards of current medical practice and applicable state law.

Classifying Benefits

Reference:
42 U.S.C. 300gg-26
42 U.S.C. 18031 (j)
45 CFR 146.136 (c)(2)(ii)(A)
45 CFR 146.136 (c)(3)(iii)(B)
45 CFR 146.136(c)(3)(iii)(C)
45 CFR 156.115 (a) (3)

Description of Standards or Requirements:
We shall assign MH/SUD benefits to each of the six classifications and permitted sub-classifications. We must apply the same standards to medical/surgical benefits and to mental health or substance use disorder benefits in determining the classification or sub-classification in which a particular benefit belongs. We shall demonstrate that mental health or substance us disorder benefits are covered in each classification in which medical/surgical benefits are covered.

Financial Requirements and Quantitative Treatment Limitations

Reference:
42 U.S. C. 300gg-26
42 U.S.C. 18031 (j)
45 CFR 146.136 (c)(2)(i)
45 CFR 146.136 (c)(3)(i)(A)
45 CFR 146.136(c)(3)(i)(B)(1)
45 CFR 146.136(c)(3)(i)(B)(2)
ACA FAQ 34 Q3
45 CFR 156.115(a)(3)

Description of Standards or Requirements:
Your coverage shall not apply any financial requirements or quantitative treatment limitation on mental health or substance use disorder benefits in any classification (or applicable sub-classification) that is more restrictive than the predominant financial requirement or quantitative treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification (or applicable sub-classification).

Cumulative Financial Requirements and Cumulative Quantitative Treatment Limitations

Reference:
45 U. S. C. 300gg-26 (3)
45 CFR 146.136 (c) (3) (v)

Description of Standards or Requirements:
We shall not apply any cumulative financial requirement or quantitative treatment limitation to mental health or substance use disorder benefits in a classification that accumulates separately from any established for medical/surgical benefits in the same condition.

Non-Quantitative Treatment Limitations (NQTLs)

Reference:
45 U. S. C. 300gg-26 (a)(3)(A)
42 U. S. C 18031 (j)
45 CFR 146.136 (c) (4) (1)
45 CFR 56.115 (a) (3)

Description of Standards or Requirements:
We shall justify the application of any NQTL to mental health or substance use disorder benefits within a classification of benefits (or applicable sub-classification) such that any processes, strategies, evidentiary standards, or other acts used to apply a limitation, as written and in operation, are comparable to, and are applied no more stringently than the processes, strategies, evidentiary standards, or other facts used to apply the limitation to medical/surgical benefits within the classification (or applicable sub-classification).

NQTLs shall be categorized as: 1) medical management which includes issuer prior authorization, concurrent review and retrospective review protocols and the medical necessity criteria utilized in conjunction with them; 2) exclusions of coverage; e.g., experimental or investigational; 3) plan provider network matters-credentialing criteria network tiering; 4) network adequacy; i.e. plan MH/SUD network performance; 5) provider reimbursement rates; 6) prescription drugs; 7) other NQTLs as identified by the issuer-restrictions on facility type, geographical location.

Disclosure

Reference:
45 CFR 146.136 (d) (1)
45 CFR 146.136 (d) (2)
45 CFR 146.136 (d) (3)
45 CFR 147.136 (b) (2)
45 CFR 147.136 (b) (3)

Description of Standards or Requirements:
We shall ensure that we comply with all availability of policy or contract information and related disclosure obligations regard: 1) criterial for medical necessity determinations; 2) reasons for denial of services; 3) information relevant to medical/surgical, mental health, and substance use disorder benefits; 4) rules regarding claims and appeals, including the right of the claimants to free reasonable access and copies of documents, records and other information including information on medical necessity criteria for both medical/surgical benefits and mental health and substance use disorder benefits, as well as the processes, strategies, evidentiary standards, and other factors used to apply a NQTL with respect to medical/surgical benefits and mental health or substance use disorder benefits under your plan.

If we contract with a managed behavioral health organization (MBHO) to provide any or all our mental health or substance use disorder benefits, we ensure that we coordinate with the MBHO to secure compliance with MHPAEA.