Annual member notices
Required state and federal notices for members of the Capital BlueCross Family of Companies
Required state and federal notices for members of the Capital BlueCross Family of Companies
As a valued member, you have access to a suite of quality programs, services, and educational tools to help you live healthy and be well — all from the convenience of your computer or mobile device.
Log in or register to access your Capital BlueCross secure account. It is your personalized area for managing your plan, from finding in-network providers to viewing your Explanations of Benefits (EOBs) or member ID card. You also can update your contact information and communication preferences and find your responsibilities and rights as a member as well as information on advanced care planning and communicating care goals.
If your plan includes prescription drug benefits, your secure account is your one-stop shop to:
For the most up-to-date prescription drug information and updates to the list of covered drugs, view the drug lists and forms.
If you would like paper copies of the materials available, call Member Services at the number on the back of your member ID card.
Note: The organization may limit communication of updates to “negative” formulary changes, such as changes that result in restrictions or replacements, and may limit such communications to affected members and their providers.
Preauthorization is the medical necessity review completed before you receive certain healthcare services. Preauthorization ensures the services are medically appropriate. In-network providers for 2021 (including BlueCard® facilities that provide inpatient services outside Capital BlueCross’ 21-county service area) are responsible for obtaining preauthorization. If you receive an outpatient service by an out-of-network provider or from a BlueCard facility outside our service area, you are responsible for obtaining authorization, if required. If you do not obtain preauthorization, your claim may be reviewed for medical necessity and you may be responsible for paying the cost of the service. Search for participating providers, hospital, and labs, and learn more about preauthorization requirements. Also, check your benefit plan documents for a complete list of services that require preauthorization.
Capital BlueCross and our family of companies provide benefits for mastectomy-related services in accordance with the Women’s Health and Cancer Rights Act of 1998.These benefits include all stages of reconstruction and surgery to achieve symmetry between breasts; prostheses; and complications resulting from a mastectomy, including lymphedema. Please call the Member Services number on your member ID card if you have questions about these benefits.
Under federal law, group health plans and health insurers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, the plan or insurer may pay for a shorter stay if the attending provider (e.g., provider, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also under federal law, plans and insurers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain preauthorization.
Pennsylvania Act 81 automatically provides health insurance coverage under a subscriber's plan to newborns for the first 31 days following birth. Any costs for benefits provided to the newborn child will be applied to the subscriber's cost-sharing amounts. Separate cost-sharing amounts will not apply to the newborn child unless and until the child is separately enrolled as a dependent in accordance with the terms of the subscriber's Certificate of Coverage.
As children transition into young adults, it is important they receive the right healthcare services. Usually by the time young adults finish school, they should move their care from a pediatrician to a Primary Care Physician (PCP). To help with the transition to adult care, visit MyCare Finder, our online tool to view the most up-to-date listings of providers in your area. You can also compare treatment costs and learn more about providers that are accepting new patients, their specialties, hours, and hospital affiliations.
Your pediatrician’s office may be able to recommend an in-network PCP for adults. Also remember to speak with them about sending your child’s medical records to the new provider.
Medication synchronization (Med Sync) is now available to eligible members with Capital BlueCross prescription drug coverage. This is for members who take two or more maintenance (or long term) prescription drugs—that is, medication taken on a regular basis to manage chronic conditions such as high blood pressure or high cholesterol—and refill at in-network retail pharmacies.
If this applies to you, you can work with your pharmacist to synchronize your refills of these drugs to reduce the number of times you need to visit your retail pharmacy.
Ask your pharmacist if Med Sync is available for you and how to get started.
Capital BlueCross is now offering a Split Fill program to members who are new to certain specialty drugs, which can be hard to tolerate or may not be effective for you. For specialty drugs that you haven’t taken before, you will receive a smaller initial quantity at a pro-rated cost—saving you money if you need to change dosages or if you need to stop taking it because you can’t tolerate the drug well or it isn’t effective.
If you are prescribed one of these drugs, the specialty pharmacist will ask if you want to participate in the program. Because these specialty drugs are filled and delivered through a specialty pharmacy, you won’t need to make multiple trips to the pharmacy in order to participate in the program. If you choose to participate in the Split Fill program, you will work with your specialty pharmacist to split the fill in half, which can occur for up to three months to ensure drug toleration and effectiveness. Once it is determined that the drug works for you, your pharmacist can start sending your full prescription quantity each month. Cost share is subject to the terms and conditions of your plan.
This program is not available for all members. If eligible, your specialty pharmacist will ask if you would like to participate in the Split Fill program.
Capital BlueCross currently offers nutritional counseling for members with chronic conditions. Effective upon your plan’s renewal on or after January 1, 2021, these members will now receive 20 visits in a benefit period, including nutritional counseling offered through Capital BlueCross Virtual Care.
Benefits for nutritional counseling include counseling and education for treatment of chronic conditions, such as heart disease, cancer, eating disorders, and other conditions where dietary modifications are medically necessary.
This 20-visit limit does not apply to nutritional counseling benefits for obesity and diabetes, which may have different limits per benefit period, or nutritional guidance offered at our Capital BlueCross Connect health and wellness centers. Contact Member Services at the number on the back of your member ID card for more information.
Nutritional guidance offered at our Capital BlueCross Connect health and wellness centers is open to all members—you do not need to have a chronic condition to sign up. All members receive a free consultation plus three free follow-up appointments per calendar year with one of our certified health coaches. To set up an appointment for nutritional guidance at one of our Capital BlueCross Connect locations, call 855.505.2583 or visit Capital BlueCross Connect.
At Capital BlueCross, we are committed to providing you with the highest quality healthcare products and services. An important part of this commitment is our pledge to do everything we can to protect your nonpublic, personal financial information.
Capital BlueCross does not sell customer information. We do not disclose your nonpublic, personal financial information, except as permitted by law. We do not disclose this information, even when our member relationships end, except as permitted by law.
We collect nonpublic, personal financial information about you from the following sources:
You can help fight the rising costs of healthcare fraud by monitoring claims processed under your plan. When you receive an Explanation of Benefits (EOB) or view it from your secure account, look for discrepancies such as the date(s) of service, the provider’s information, or the procedure performed. Protect yourself against medical identity theft by guarding your member ID card as you do your credit card.If you suspect fraud, or believe you are a victim of medical identity theft, report it immediately in any of the following ways:
Let our Utilization Management and Member Services staff help you with questions about preauthorization or your health coverage. Call Member Services at the number on the back of your member ID card or for Utilization Management, call 800.962.2242 (TTY: 711). You may also contact us online with any questions. Emailed questions are reviewed Monday through Friday, 8:00 AM - 6:00 PM. Member Services representatives will make every effort to respond within 24 hours or one business day of receiving your inquiry.
As a member of the Capital BlueCross family of companies, you have certain rights and responsibilities. The success of your treatment and your satisfaction depends, in part, on you taking responsibility as a patient. Acquainting yourself with your rights and responsibilities will help you take a more active role in your healthcare.
Keystone Health Plan® Central, and its network of doctors and other providers of services, do not discriminate against members based on race, sex, religion, national origin, disability, age, sexual orientation, gender identity, or any other basis prohibited by law. As a member of the Children’s Health Insurance Program (CHIP) of Pennsylvania, you have certain rights and responsibilities.
Clinical medical necessity determinations are based only on the appropriateness of care and service and the existence of coverage. We do not reward, reimburse, or provide a bonus to individuals on the basis of utilization, issuance of denials of coverage, or provision of financial incentives of any kind to encourage decisions that may result in underutilization or that could negatively influence the provision of healthcare services.
We do not use incentives to encourage barriers to care and service, nor do we make decisions about hiring, promoting, or terminating providers or other staff based on the likelihood, or the perceived likelihood, that the provider or staff member supports, or tends to support, denial of benefits.
If you disagree with our adverse benefit determination, you may seek internal review of that determination by submitting a written appeal. An internal, expedited review may be requested if the situation is considered life-threatening or the member's health is in jeopardy. This expedited review may be requested by contacting Member Services using the telephone number provided on the determination letter or mailing the request to the address provided on the determination letter. We respond with an internal appeal review determination as soon as possible, but no later than 72 hours of receiving the appeal request. You also may request an external appeal through an independent review organization of a final, internal, adverse benefit determination pertaining to medical necessity. Please refer to your benefit plan documents for specific guidelines on your right to appeal. For more information on the appeal process, call the Member Services number on your member ID card.
In-network providers handle all claims paperwork for hospital and medical care and automatically send them to us for processing. However, you may be responsible for submitting claims for certain services. For instance, if you visit an out-of-network provider, you will need to confirm if they are submitting a claim on your behalf, and if they are not, you will need to submit a claim for any covered services. Also, you may need to provide information related to your eligibility for coverage from time to time. For example, you may need to respond to questions from us about other insurance coverage to coordinate benefits or resolve other-party liability issues. If you do not return the requested information, we may withhold payment of a claim until we receive the information. You may print claim forms or you may contact us to request they be mailed to you.
If you need these services, call 800.962.2242 (TTY: 711). If you believe we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator. You can file a grievance in person or by mail, fax, or email at:
If you need help filing a grievance, our civil rights coordinator is available to help you. You can also file a civil rights complaint electronically with the U.S. Department of Health and Human Services, Office for Civil Rights through the Office for Civil Rights Complaint portal, or by mail or phone at:
The information provided is not intended to replace the advice of your healthcare provider. Please consult your healthcare provider if you have any questions or concerns about the information provided, as your healthcare provider is familiar with your personal medical history.
Benefits vary by type of product and benefit design; therefore, not all programs or issues addressed may be available, covered, or applicable to your specific coverage. Please refer to your benefit documents (also known as "Certificate of Coverage") or contact Member Services at the number on the back of your plan member ID card.