General disclaimers, Blue cross power select HMO, Blue cross ppo, Health insurance california, California dental insurance, Group health insurance california,

Please read the following information so that you will know which physicians, provider groups, hospitals/facilities and other providers are available to you under your Blue Cross (i.e., either Blue Cross of California or BC Life & Health Insurance Company) benefit plan. This information is being provided for general information purposes only. Please refer to the applicable plan for information on plan benefits, conditions, limitations and exclusions.

1. The listing of providers does not constitute a recommendation of any physician, provider group, hospital/facility or other provider.

2. We have made every effort to ensure the accuracy of this on-line directory of providers. However, we cannot guarantee that this information has not changed since being provided to us and posted. Provider participation varies depending on the type of plan and coverage selected. Please review your evidence of coverage (EOC) or certificate of coverage (COC) for more information specific to your benefit plan, or contact the toll free customer service number located on your ID card.

3. The physicians, provider groups, hospitals/facilities and other providers that are part of the network of providers referred to by this directory are independent contractors who exercise independent judgment and over whom Blue Cross has no control or right of control and are not agents or employees of Blue Cross. If you, or a covered family member, select a provider in the network, either directly or by referral from another provider, you are seeking care from that provider, not Blue Cross. The provider exercises independent, professional judgment. It is your provider’s responsibility to discuss treatment options with you, even those that might not be eligible for benefits under your plan. Blue Cross’ decisions about whether any medical service or supply is covered under your benefit plan are insurance benefit decisions only and are not the provision of medical care. Blue Cross is not responsible for, does not provide, and does not hold itself out as the provider of your medical care. Only the doctors who treat you can provide medical care and only those doctors are responsible for any negligence in providing your medical care. If a service or supply is not eligible for benefits under your plan, you and your provider are free to proceed with that service or supply knowing that benefits are not available under your plan.

4. Some plans require prior authorization for certain services. Please refer to your EOC or COC for more information regarding any authorization processes applicable to your plan. Failure to do so may result in additional costs to you including, but not limited to, deductibles, co-payments, coinsurance or the services may be excluded by your benefit plan. Please call the toll free phone number on your ID card for further assistance.

5. Please verify with the provider you select that the provider is currently participating in the network at the location in which you are seeking care.

6. For behavioral health services, please verify that Blue Cross of California (Blue Cross) administers your mental health and chemical dependency benefit prior to using this Provider Finder.

7. For behavioral health provider groups, please note that each individual professional in the group may not be listed on Provider Finder. Please call the group directly to verify those professionals participating in Blue Cross’ Behavioral Health network.

Blue Cross HMO, except Medi-Cal HMO, Healthy Families HMO, AIM HMO and Blue Cross Senior Secure HMO [Blue Cross of California]

1. Generally, health care services provided to HMO members are covered only when they are provided or coordinated by the member’s primary care physician (PCP) or medical group/IPA except for emergencies, services provided by Ready Access, basic OB/GYN services within the medical group/IPA, or services for mental health or chemical dependency.

2. If you are an HMO member, usually you will need to contact your PCP for referral authorization to see a specialist. Without a referral from your PCP, you may be responsible for up to the full cost of those services. Specialist services must be coordinated or authorized by your PCP or medical group/IPA, except for emergencies, services provided by Ready Access, basic OB/GYN services within medical group/IPA and services for mental health or chemical dependency.

3. Also, you do not need a referral see specialists in the Direct Access program, which allows you to self-refer to allergists, dermatologists, or otolaryngologists (ENTs) within your medical group/IPA. Before seeking services, please contact the specialist physician’s office to confirm that the specialist is still affiliated with your medical group/IPA.

4. When enrolling in an HMO plan, you will need to select a medical group/IPA within 30 miles of your home or work.

5. When enrolling, if you select an IPA, you must also select a PCP. Each family member may select a different PCP.

6. Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call the health plan at the customer service telephone number listed on your ID card to ensure that you can obtain the health care services that you need.

7. You do not need a referral to see a behavioral health specialist. You may self-refer to a specialist in Blue Cross of California’s Behavioral Health network. Please confirm that the specialist is a participating provider at the time and location of service. For more information regarding mental health or chemical dependency services, please refer to the behavioral health disclaimer section.

8. If you are a current HMO member and need further assistance, please call customer service at the phone number on your ID card.

1. Generally, health care services provided to Blue Cross Power Select HMO members are covered only when they are provided or coordinated by the member’s Primary Care Physician (PCP) or medical group/IPA except for emergencies, services provided by Ready Access, basic OB/GYN services within the medical group/IPA, or services for mental health or chemical dependency.

2. You do not need a referral authorization to see Gynecology, or Obstetrics and Gynecology, specialists who are part of your medical group/IPA. You do not need a referral to see specialists participating in the Direct Access program. Before seeking services, contact the specialist physician’s office to confirm specialist is still affiliated with your medical group/IPA.

3. When enrolling in the Blue Cross Power Select HMO plan, you must select a medical group/IPA located within 30 miles of your home or your work location.

4. When enrolling, if you select an IPA, you must also select a Primary Care Physician (PCP). Each family member may select a different PCP.

5. All inpatient admissions must be referred by your Primary Care Physician (PCP). Referrals to these hospitals are determined by the medical group/IPA you have selected.

6. You do not need a referral authorization for services for mental health care. To search for mental health providers, select the Behavioral Health Network on the Plan selection page.

7. If you are a current Blue Cross Power Select HMO member and need further assistance, please call customer service at the phone number on your ID card.

1. If you are a POS member, you must select a medical group/IPA in the HMO network, but you may choose to “opt-out” of the HMO provider network to obtain services from a PPO provider or out-of-network provider. Your out-of-pocket costs will differ depending upon the provider network that you use. You do not need a referral to see a behavioral health specialist. You may self-refer to a specialist in Blue Cross of California’s Behavioral Health network. Please confirm that the specialist is a participating provider at the time and location of service. For more information regarding mental health or chemical dependency services, please refer to the behavioral health disclaimer section.

a. Generally, health care services provided to POS members using the HMO coverage are covered only when they are provided or coordinated by the member’s primary care physician (PCP) or medical group/IPA except for emergencies, services provided by Ready Access, basic OB/GYN services within the medical group/IPA, or services for mental health or chemical dependency.

b. When you are using your HMO coverage, you will typically need to contact your PCP for referral authorization to see a specialist. Without a referral from your PCP, you may be responsible for up to the full cost of those services requiring a referral. Specialist services must be coordinated or authorized by your PCP or medical group/IPA, except for emergencies, services provided by Ready Access, basic OB/GYN services within medical group/IPA and services for mental health or chemical dependency.

c. Also, you do not need a referral to see specialists in the Direct Access program, which allows you to self-refer to allergists, dermatologists, or otolaryngologists (ENTs) within your medical group/IPA. Before seeking services, please contact the specialist physician’s office to confirm that the specialist is still affiliated with your medical group/IPA.

d. When enrolling, you will need to select a medical group/IPA within 30 miles of your home or work.

e. When enrolling, if you select an IPA, you must also select a PCP. Each family member may select a different PCP.

f. If you are a POS member using your HMO coverage, you must obtain your behavioral health or chemical dependency services from a Blue Cross Behavioral Health network provider in order to receive plan benefits. Please contact the behavioral health provider directly to verify participation in the network and to confirm that he/she is accepting new patients.

g. Outpatient professional mental health or chemical dependency services do not require an authorization or referral from your primary care physician (PCP) or medical group/IPA. Your PCP, however, may be able to recommend the appropriate type of provider for your needs.

h. Inpatient admissions to mental health or chemical dependency hospitals are covered ONLY when authorized by Blue Cross. Pre-authorization from Blue Cross can be obtained by calling the toll-free number on your member ID card.

i. Please refer to your evidence of coverage or certificate of coverage for specific information or requirements related to your mental health or chemical dependency benefits. If you have questions or need further assistance, please call the toll-free customer service number on your member ID card.

a. If you are a POS member using the PPO coverage, you may choose to receive care from either a participating or non-participating provider. The level of benefits you receive usually depends on your choice of provider. Participating providers have agreed to accept discounted rates for services covered by your benefit plan. If you choose to receive care from providers who are not part of the PPO network, your out-of-pocket costs will be higher.

b. If you are a POS member using your PPO coverage, you may choose to receive care from either a Blue Cross participating or non-participating behavioral health provider. The level of benefits you receive usually will depend on your choice of provider. Participating providers have agreed to accept discounted rates for services covered by your benefit plan. If you choose to receive care from providers who are not part of the Blue Cross Behavioral Health network, your out-of-pocket costs will be higher.

c. Pre-authorization requirements for outpatient mental health or chemical dependency services vary depending upon your plan benefits. Inpatient admissions to mental health or chemical dependency facilities or hospitals may require pre-authorization from Blue Cross, except in emergencies.

2. Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call the health plan at the customer service telephone number listed on your ID card to ensure that you can obtain the health care services that you need.

3. If you are a current POS member and need further assistance, please call customer service at the phone number on your Blue Cross ID card.

Blue Cross PPO (Prudent Buyer) [Blue Cross of California or BC Life & Health Insurance Company, see your ID card]

1. If you are a PPO health plan member, you may choose to receive care from either a participating or non-participating provider. The level of benefits you receive usually depends on your choice of provider. Participating providers have agreed to accept discounted rates for services covered by your plan, and benefits for the services of non-participating providers may be limited. If you choose to receive care from providers who are not part of the PPO network, your out-of-pocket costs will be higher.

2. (For members of an employer sponsored group plan with 50 or fewer employees or individuals under age 65 and their families).

a. Hospitals with a Preferred Participating status will not have any additional co-payment amounts for services rendered.

b. Hospitals that do not have a preferred participating status may require additional co-payments as determined by your contract.

3. Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call the health plan at the customer service telephone number listed on your ID card to ensure that you can obtain the health care services that you need.

4. If you are a current PPO member and need further assistance, please call customer service at the phone number on your ID card.

Blue Cross EPO (Prudent Buyer), excludes Healthy Families EPO, AIM EPO and MRMIP [Blue Cross of California or BC Life & Health Insurance Company, see your ID card]

1. The EPO plan provides benefits for services of participating PPO providers ONLY. There are no benefits for non-participating providers unless the service is in connection with an emergency, urgent care or an authorized referral. If you choose to receive care from a non-participating provider, other than emergency, urgent or authorized referral services, you will be responsible for the full cost of the services.

3. If you are a current EPO member and need further assistance, please call customer service at the phone number on your ID card.

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1. Blue Cross HMO Plans, except Medi-Cal HMO, Healthy Families HMO, AIM HMO and Blue Cross Senior Secure [Blue Cross of California]:

a. In order to receive benefits under your HMO plan, you must access mental health or chemical dependency services from a Blue Cross of California (Blue Cross) Behavioral Health network provider. Please contact the provider directly to verify participation in the network and confirm that he/she is accepting new patients.

b. Outpatient professional mental health or chemical dependency services do not require an authorization or referral from your primary care physician (PCP) or medical group/IPA. Your PCP, however, may be able to recommend the appropriate type of provider for your needs.

Inpatient admissions to mental health or chemical dependency facilities or hospitals are covered ONLY when authorized by Blue Cross. Pre-authorization from Blue Cross can be obtained by calling the toll-free number on your member ID card.

Inpatient admissions to mental health or chemical dependency facilities or hospitals do not require a referral or pre-authorization from your primary care physician, medical group/IPA or Blue Cross.

e. Please refer to your evidence of coverage or certificate of coverage for specific information or requirements related to your mental health or chemical dependency benefits. If you have questions or need further assistance, please call the toll-free customer service number on your member ID card.

2. Blue Cross PPO (Prudent Buyer) [Blue Cross of California or BC Life & Health Insurance Company, see your ID card]

a. If you are a PPO member, you may choose to receive care from either a participating or non-participating behavioral health provider. The level of benefits you receive usually depends on your choice of provider. Participating providers have agreed to accept discounted rates for services covered by your plan, and benefits for the services of non-participating providers may be limited. If you use a provider that is not in the Prudent Buyer (PPO) network, your out-of-pocket costs will be greater.

b. Pre-authorization requirements for outpatient mental health or chemical dependency services vary depending upon your plan benefits. Inpatient admissions to mental health or chemical dependency facilities or hospitals may require pre-authorization from Blue Cross, except in emergencies.

c. Please refer to your evidence of coverage or certificate of coverage for specific information or requirements related to your mental health or chemical dependency benefits. If you have questions or need further assistance, please call the toll-free customer service number on your member ID card.

3. Blue Cross EPO (Prudent Buyer), excludes Healthy Families EPO, Access for Infants & Mothers “AIM” EPO and Major Risk Medical Insurance Plan “MRMIP” [Blue Cross of California or BC Life & Health Insurance Company, see your ID card]

a. In order to receive benefits under your EPO plan, you must access mental health or chemical dependency services from a provider in Blue Cross of California’s (Blue Cross) Behavioral Health network. There are no benefits for services rendered by non-participating providers, except in emergencies.

b. Pre-authorization requirements for outpatient mental health or chemical dependency services vary depending upon your plan benefit. Inpatient admissions to mental health or chemical dependency facilities or hospitals may require pre-authorization from Blue Cross, except in emergencies.

a. If you are a POS member using your HMO coverage, you must obtain your behavioral health or chemical dependency services from a Blue Cross of California (Blue Cross) Behavioral Health network provider in order to receive plan benefits. Please contact the behavioral health provider directly to verify participation in the network and to confirm that he/she is accepting new patients.

c. Inpatient admissions to mental health or chemical dependency facilities or hospitals are covered ONLY when authorized by Blue Cross. Pre-authorization from Blue Cross can be obtained by calling the toll-free number on your member ID card.

d. Please refer to your evidence of coverage or certificate of coverage for specific information or requirements related to your mental health or chemical dependency benefits. If you have questions or need further assistance, please call the toll-free customer service number on your member ID card

a. If you are a POS member using your PPO coverage, you may choose to receive care from either a participating or non-participating Blue Cross of California (Blue Cross) behavioral health provider. The level of benefits you receive usually will depend on your choice of provider. Participating providers have agreed to accept discounted rates for services covered by your benefit plan, and benefits for the services of non-participating providers may be limited. If you choose to receive care from providers who are not part of the Blue Cross Behavioral Health network, your out-of-pocket costs will be higher.

a. Members with Blue Cross of California Standard Medicare Supplement Plan A must receive services from a Medicare participating provider in order to be eligible for plan benefits.

b. Members with Blue Cross of California Medicare Select Plans and Select PLUS must receive inpatient hospital services from Blue Cross Senior Select hospitals in order to be eligible for some plan benefits.

c. Members with Blue Cross of California Senior Classic, Select, or Smart Choice Plans must use Participating Prudent Buyer Providers in order to be eligible for some plan benefits.

d. If you are a current member, please refer to your evidence of coverage booklet for specific benefits and exclusions applicable to your plan. If you need further assistance, please call the number on your ID card. If you are not a current member and need assistance, please call us at 1-800-765-2585.

If you are a Medicare eligible individual enrolled in a Blue Cross Senior Secure HMO (Medicare Advantage) Plan:

a. You should select a Participating Medical Group (PMG) or Independent Practice Association (IPA) located within 30 miles of your home or work location. If you select an Independent Practice Association (IPA), you must choose a primary care physician (PCP). Your PCP will be responsible for all your healthcare needs, including admission to the hospital and referrals to specialists.

b. You do not need a referral to see participating Prudent Buyer (PPO) physicians including specialists (not affiliated with your chosen medical group) if you are using the Choices Plus program. This benefit is limited to three (3) physician office visits per year for a $ 30 co-payment per visit. Services specially excluded from coverage under Blue Cross Senior Secure are not covered through the Choices Plus Self-Referral Benefit. The Choices Plus benefit cannot be used for emergency or out-or-area urgently needed services. The Choices Plus program covers the physician office visit only and does not include any services other than the physician office visit. All inpatient hospital admissions must be referred by your PCP.

c. Members enrolled in a Blue Cross Senior Secure Plan that includes dental benefits do not need a referral authorization from the PCP to access dental benefits for covered dental services. However, those dental services must be provided by a participating dentist.

d. Please refer to your evidence of coverage booklet for specific benefits and exclusions applicable to your plan. If you need further assistance, please call the number on your ID card. If you are not a current member and need assistance, please call us at 1-800-765-2585.

State Sponsored Programs (includes Medi-Cal, Healthy Families HMO, Healthy Families EPO, Access for Infants & Mothers “AIM” EPO and Major Risk Medical Insurance Plan “MRMIP”) [Blue Cross of California]

1. HMO Plans (Medi-Cal HMO, Healthy Families HMO and Access for Infants & Mothers “AIM” HMO):

a. If you are a State Sponsored Programs HMO member, usually you will need to contact your primary care provider (PCP) for a referral authorization to see a specialist. Female members do not need a referral authorization to see contracted Gynecology (GYN) or Obstetrics and Gynecology (OB/GYN) specialists who are part of the contracted PCP’s medical group/IPA. To select a participating OB/GYN as a “woman’s principal health care provider” or to obtain the names of OB/GYN's who have a referral arrangement with your PCP, simply contact customer service at the number indicated on your ID card.

b. For State Sponsored Programs HMO members, the list of participating specialists is available through your PCP. You must first call your PCP for a referral to one of the specialists. If you would like help choosing a specialist, please call your PCP or the customer service number on your Blue Cross of California ID card.

2. EPO Plans (Healthy Families EPO, Access for Infants & Mothers “AIM” EPO and Major Risk Medical Insurance Plan “MRMIP”):

a. The Blue Cross State Sponsored Programs EPO plan provides benefits to members for services from EPO participating providers only. There are no benefits for non-participating providers unless the services have been authorized by Blue Cross or are in connection with emergency or urgent care. If you choose to receive care from a non-participating provider, and the services have not been authorized by Blue Cross, you may be responsible for up to the full cost of the services.

3. Behavioral Health – Healthy Families HMO and Access for Infants & Mothers “AIM” HMO:

a. In order to receive benefits under your Healthy Families HMO or Access for Infants & Mothers (AIM) HMO plan, you must access mental health or chemical dependency services from a Blue Cross of California (Blue Cross) Behavioral Health network provider. Please contact the provider directly to verify that he/she is accepting new patients.

4. Behavioral Health – Healthy Families EPO, Access for Infants & Mothers “AIM” EPO and Major Risk Medical Insurance Plan “MRMIP”:

a. In order to receive benefits under your Healthy Families EPO, Access for Infants & Mothers (AIM) EPO or Major Risk Medical Insurance Plan (MRMIP) plan, you must access mental health or chemical dependency services from a Blue Cross Behavioral Health network provider. There are no benefits for such services rendered by non-participating providers, except in emergencies.

b. Pre-authorization from Blue Cross is required prior to seeking outpatient or inpatient mental health or chemical dependency services, except for emergency services. You or your provider should call the toll-free number on your member ID card to obtain pre-authorization from Blue Cross.

c. Please refer to your evidence of coverage or certificate of coverage for specific information or requirements related to your mental health or chemical dependency benefits. If you have questions or need further assistance, please call the toll-free customer service number on your member ID card

Prescription Drug Coverage for State Sponsored Programs (HMO and EPO plans) is a managed pharmacy program that provides benefits for covered prescription drugs you purchase from a licensed qualified pharmacy. When you use a network pharmacy, you receive in-network benefits and the convenience of never having to file a claim. If you purchase prescription drugs at a non-network pharmacy, you may be responsible for up to the full retail price. Please check your evidence of coverage for more information specific to your benefit plan.

If you have Prescription Drug Coverage for State Sponsored Programs, you can get answers to your questions by calling the customer service number on your ID card.

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Dental PPO [BC Life & Health Insurance Company]

1. PPO Dental offers you and your enrolled family members access to a large statewide network of participating dentists. If you are a PPO Dental plan member, you may choose to receive care from either a participating or non-participating dental office or dentist. The level of benefits you receive usually depends on your choice of provider. Participating dentists have agreed to accept discounted rates for services covered by your plan, and benefits for the services of non-participating providers may be limited. If you choose to receive care from a non-participating dentist, your out-of-pocket costs will be higher.

2. If you are a current PPO Dental member and need further assistance, please call customer service at the phone number on your ID card.

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Dental EPO [BC Life & Health Insurance Company]

1. The Dental EPO plan provides benefits for services rendered by participating dental office or participating dentists ONLY, except for limited coverage of emergency services. If you are a Dental EPO member and you choose to receive care from a non-participating dentist, you will be responsible for the full cost of the services. If you are temporarily outside of California and need emergency services, you may obtain care from any licensed dentist. Please check your evidence of coverage or certificate of coverage, or call the phone number on your ID card for more information on out-of-state emergency services.

2. If you are a current Dental EPO member and need further assistance, please call customer service at the phone number on your ID card.

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Dental Net HMO [Blue Cross of California]

1. To enroll in the Dental Net plan, you must select a participating dental office or dentist. This participating dentist will be responsible for coordinating all of your dental care, including referrals to see a participating specialist.

a. (For members of an employer sponsored group plan with 51 or more employees)

Each family member may select a different participating dentist who will be responsible for coordinating all their dental care.

b. (For members of an employer sponsored group plan with 50 or fewer employees or individuals under 65 and their families)

All members of your family must select the same participating dental office or dentist.

2. If you are a current Dental Net member and need further assistance, please call customer service at the phone number on your ID card.

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Dental Select HMO [Blue Cross of California]

1. To enroll in the Dental Select HMO plan, you must select a participating dental office or dentist.

a. (For members of an employer sponsored group plan with 51 or more employees)

Each family member may select a different participating dentist who will be responsible for coordinating all their dental care.

b. (For members of an employer sponsored group plan with 50 or fewer employees or individuals under 65 and their families)

All members of your family must select the same participating dental office or dentist.

2. If you are a current Dental Select HMO member and need further assistance, please call customer service at the phone number on your ID card.

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National Dental PPO [BC Life & Health Insurance Company]

1. National Dental PPO offers you and your enrolled family members access to a large nationwide network of participating dentists. If you are a National Dental PPO plan member, you may choose to receive care from either a participating or non-participating dental office or dentist. The level of benefits you receive usually depends on your choice of provider. Participating dentists have agreed to accept discounted rates for services covered by your plan, and benefits for the services of non-participating providers may be limited.

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Prescription Drug Coverage (except for State Sponsored Programs see below) [when included as part of your medical plan]

. Prescription Drug Coverage is a managed pharmacy program that provides benefits for covered prescription drugs purchased from a licensed qualified pharmacy. When you use a network pharmacy, you receive in-network benefits and the convenience of never having to file a claim. If you purchase prescription drugs at a non-network pharmacy, you must pay the pharmacy the full retail price of the drugs and then submit a claim form to receive any covered benefits, and benefits for prescriptions purchased at non-participating pharmacies are limited.

2. If you have Prescription Drug Coverage, you can get answers to your questions by calling the customer service number on your ID card.

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