Member frequently asked questions

Will I have to pay anything when I see my doctor or get drugs?

Most Blue Care Network plans require a copayment for some services. Office visits, for example, frequently require a copayment; so do emergency room visits. You pay this fee when you receive your medical care. Depending on your coverage plan, you may also be responsible for a deductible, which requires that you meet a fixed annual amount for one person or for your family before services are covered. For more information, read your Certificate of Coverage booklet and accompanying riders.

I have drug coverage. Why do I still pay for prescriptions?

Drug coverage almost always requires that the member make a copayment — a set amount or a percentage of the cost of the drug. Drug coverage varies. Many of our drug plans encourage members to ask for generic drugs by requiring a higher copayment for brand name drugs. For example:

If you have a BCN prescription drug rider, you have prescription drug coverage. The rider came with your BCN Certificate of Coverage. If you can't find your rider, contact us , and ask about the plan your group purchased for you.

Why don't you cover the drug that my doctor prescribed?

Some medications are not covered by BCN; some are not covered by your group plan. Also some drugs in BCN's formulary have clinical restrictions and some require prior authorization. When several drugs have the same effect, we select the medication that is least costly because drug pricing is not connected to how well a drug works. Drugs that require prior authorization are covered only if your primary care physician and BCN agree that the drug is medically necessary for your treatment.

What is a formulary?

A formulary is a regularly updated list of medications that represent the clinical judgment of Michigan physicians, pharmacists and other experts in health care diagnosis and treatment. Medications are selected for BCN's formulary based on clinical effectiveness, safety and opportunity for cost savings and grouped into copayment tiers.

Why don't you cover the procedure my doctor is suggesting?

To be covered, a service must meet our medical criteria and be covered under your benefit plan. There are differences between benefit plans. Your coverage depends on what you or your group has selected. Covered services must also meet our guidelines of service to be payable. Your specialty care, for example, must be provided by a specialist in our network, and your PCP must provide a referral to him or her. For a complete description of your coverage, please refer to your Certificate of Coverage booklet.

Why can't I see the specialist I've seen before?

Your specialist care must be provided by a specialist in our network, and your PCP must provide a referral to him or her. Many BCN PCPs belong to physician groups. Each physician group has developed relationships with specialists in BCN's network. Usually these specialists have the same hospital affiliations as the PCPs who belong to a physician group. Your PCP will generally refer you to a specialist who is affiliated with his or her physician group and works out of the same hospital. This helps your PCP coordinate your care.

Why do you list doctors with closed practices in your directories? Why do doctors close their practices?

They're listed because under certain circumstances doctors with closed practices will continue to accept BCN members into their practices. Many times doctors will continue to see patients new to BCN as long as the doctor has treated them before.

Does BCN cover my visits to the emergency room?

Yes, BCN covers emergency room visits when the condition is an emergency. Normal copayments and deductibles apply.

How do I get reimbursed for medical expenditures?

If you paid a medical bill that you think should be covered, send it to us with a Member Reimbursement form (PDF). Include the original proof of payment and the treatment record or emergency report with the form.

If you paid for prescriptions that you think should be covered, send it to us with a Medco Prescription Drug Reimbursement Form (PDF). Include the original proof of payment, the name and dosage of any prescription drug as well as the original prescription receipt with the form.

What do I do if I have issues about my care?

You can contact us to resolve your concerns. If you're not happy with the result, you also have the ability to seek resolution through our grievance process. If you are employed by an ERISA-qualified group, your avenues of appeal are slightly different.

Why am I receiving a bill from the hospital or my PCP?

You should not receive a bill for authorized, covered services. The doctor, hospital or other health care provider should bill BCN directly; you simply pay any required copayment. In the event you do receive a bill or claim for medical services from a provider, do not throw it away; contact Customer Service at 800-662-6667 for assistance.

Do I need to inform BCN if I have other health insurance in addition to BCN?

Yes. If you are covered by another health care plan such as Medicare or if you have health coverage through your spouse or your auto or home insurance, you may be eligible for coordination of benefits. Your dependents may also have coverage through more than one health care plan. Coordination of your benefits often results in lower out-of-pocket expenses, even up to 100 percent coverage of your medical care in some cases. Contact us for more information .

How do I change my address, phone number or the dependents on my BCN coverage?

To change your address, phone number or the dependents on your BCN coverage, you must either contact your employer's benefit representative or, if you have individual coverage, contact us .

Report any changes in your contract within 30 days of the event. These changes may include the birth of a child, adoption or legal guardianship of a child, marriage, divorce, death, name change, new address or telephone number, Medicare eligibility, a new employer, etc. Note: If your employer's records are inaccurate, that old information will become part of our record when your employer transmits information to us, so please make sure your employer has your new address and phone number on file.

 

page modified 02/25/2010