BlueLincs HMO

When you join an HMO, you select a Primary Care Physician (PCP) who coordinates all your health care needs, including referrals to specialists.

You have no deductibles to meet, no claims to file, no preexisting condition limitations and only copayments for most services. You also have access to important preventive care benefits, which sometimes aren't covered under other health benefit plans.

BlueLincs HMO places the highest priority on safeguarding the confidentiality of our members' data. We have instituted a confidentiality committee and have written policies and procedures to ensure that your information remains private and confidential.

When you signed your application for BlueLincs coverage, you gave permission for any health care practitioner or provider to release your medical information to BlueLincs for routine business functions, such as claims payment, coordination of care, quality assessment or accreditation.

BlueLincs has written policies regarding the release of member information to parties outside the company and within the company. BlueLincs does not release sensitive medical information to employers and does not use member-identifiable information in quality measurement reports.

Member data is limited to those who need to know and is protected by physical and technological safeguards. BlueLincs' employees attend corporate compliance training upon employment and annually to reinforce protection of privacy in all settings.

Simply select a PCP listed in the Provider Finder® as a BlueLincs HMO network provider. Be sure the doctor you select is accepting new patients.

You may change your PCP up to four times each year. Simply call or write Member Services by the 20th of the month and your change will be effective the first of the following month.

Only in those unusual instances when care cannot be provided in-network, you will be referred out-of-network. But an out-of-network referral must be approved, in advance, by the BlueLincs Medical Director. When necessary, your PCP will request the referral from the BlueLincs Medical Director. If you choose on your own to seek out-of-network care, there are no benefits.

Your PCP will provide you with a referral if you need the care of a specialist. Always contact your PCP first for any care you need.

It's important to understand that you must work through your PCP. Benefits are not available if you go to a specialist without getting a referral from your PCP.

If your PCP is a member of a medical group (such as a multi-specialty clinic), you will be referred to a participating specialist affiliated within the same medical group. If you prefer a specific specialist who is participating with BlueLincs, you may want to select a PCP from the specialist's affiliated medical group. You must have a referral from your PCP before seeing any specialist.

You must have a referral from your PCP before seeing any specialist. Referrals are valid for a specific period of time or number of visits. If the specialist determines that you will need more visits or another referral beyond the authorized period, he or she will work with you and your PCP on getting the care authorized. You should always contact your PCP before receiving additional care to make sure the services are authorized.

BlueLincs has an appeals process in place for resolving complaints. The process involves two levels:

Level 1 — The appeal is reviewed by a BlueLincs medical director, a consulting physician or an administrative review committee.

Level 2 — If you are not satisfied with Level 1 determination, another appeal may be made to BlueLincs' Grievance Committee.

After all internal BlueLincs appeal procedures have been exhausted, claims may be externally reviewed by an independent organization. External review is for claims related to medical treatments that are a covered benefit, but were denied because they were deemed not medically necessary, medically appropriate or medically effective.

You may submit your complaint in two ways: by phone (1-800-580-6202) or in writing to BlueLincs Member Services, 1400 S. Boston, Tulsa, OK 74119-3618.

You do not need a referral to see a BlueLincs participating gynecologist for your annual (once every 12 months) "well woman" exam. This exam includes pap smear, pelvic exam and manual breast exam. Simply contact a BlueLincs Member Services representative at 1-800-580-6202 before you go to the doctor.

They will confirm that you have selected a participating OB/GYN. You will also receive an authorization number that you must take to your scheduled appointment.

Any follow-up care required after your routine "well woman" exam (including mammography screening) must be coordinated by your PCP.

If you need additional specialty care from an OB/GYN, your PCP will refer you to a BlueLincs participating OB/GYN within his or her participating medical group network.

You do not need a referral to see a BlueLincs participating urologist for your annual (once every 12 months) "well man" exam. This exam includes office visit and prostate exam. Simply contact a BlueLincs Member Services representative at 1-800-580-6202 before you go to the doctor.

They will confirm that you have selected a participating urologist. You will also receive an authorization number that you must take to your scheduled appointment.

Any follow-up care required after your routine "well man" exam (including a PSA test) will be coordinated by your PCP.

If you need additional specialty care from a urologist, your PCP will refer you to a BlueLincs participating urologist within his or her participating medical group network.

If your PCP does not provide maternity care, he or she can refer you to a participating obstetrician (OB) for the duration of your pregnancy. It is important to note that the majority of PCPs will refer you to an OB within their Medical Group Network. You pay the physician office copay only on your first visit to the OB physician.

If you are in your first or second trimester, you should discuss this with your PCP. He or she may refer you to a participating obstetrician for maternity care, or, if your PCP also provides maternity care, he or she may provide your care for the remainder of your pregnancy.

If you are in your third trimester, you may continue to receive care from your current doctor and still receive benefits. Contact a Member Services representative at 1-800-580-6202 if this situation applies to you. You will need an authorization for those services.

BlueLincs' PCPs are required to be on-call or have a covering physician on-call 24 hours a day. During office hours, you should be able to get an appointment for urgent care within 24 hours, even if the doctor's office has to "work you in." Routine appointments (e.g., for immunizations and checkups) are usually scheduled several weeks in advance.

After office hours, you should call your PCP's after-hours number. Then you should follow the medical advice your PCP or the doctor on call gives you. If you are unable to reach the doctor during business hours, contact Member Services for assistance.

Case management is for BlueLincs members with special medical needs. A BlueLincs nurse case manager will assist you and your physician in making sure you are receiving the most appropriate benefits for your condition (i.e. skilled nursing vs. inpatient care).

In an emergency, go to the nearest medical facility and notify your PCP within 48 hours to coordinate any necessary follow-up care.

That's what we call "urgent care." It's the type of problem that should be taken care of right away, but does not require an emergency room visit. Call your PCP and follow the advice you're given.

Discuss this with your PCP and he or she will contact either BlueLincs or the medical group they are affiliated with for prior authorization. This process includes review of the services requested using nationally approved criteria for medical necessity. You should receive notification within one week.

In an emergency, you should go to the nearest medical facility and notify your PCP within 48 hours.

In an urgent situation, simply call 1-800-810-BLUE as listed on your ID card or visit the BlueCard^® Doctor and Hospital Finder Web site at www.BCBS.com for access to the nationwide network of Blue Cross and Blue Shield providers. A representative can direct you to the nearest doctor or minor emergency center and even give you directions on how to drive there. You pay your copay just like you would at home.

Preexisting conditions are injuries, illnesses or conditions for which you previously have been diagnosed, received treatment or incurred expenses. With BlueLincs, you are covered for preexisting conditions, provided the treatment for the condition is a covered benefit.

Your BlueLincs benefits are listed on the schedule of benefits provided in your enrollment packet. Be sure to review all of the materials thoroughly. If you have any questions, please contact a Member Services representative at 1-800-580-6202.

The BlueLincs exclusions and limitations are listed on the schedule of benefits. Please review them carefully and call a Member Services representative for clarifications.

Most drugs prescribed by your PCP or a participating BlueLincs specialist are covered. However, there are exclusions. If your employer has purchased the prescription drug supplement, please refer to the outpatient prescription drug rider for a specific list of exclusions.

Prescriptions are filled as prescribed up to a 30-day supply or 100 dose units, whichever is less. Maintenance drugs may be filled up to a 90-day supply or 300 dose units, whichever is less. A copayment is applied for each 30-day amount. Therefore, a 90-day supply of maintenance drugs would require three copayments. Drugs may have different copayments based on your pharmacy benefits.

A formulary is a group of drugs that a health plan approves for its members.

BlueLincs utilizes an open-style formulary. Open-style formularies make most prescription drugs available to you within policy guidelines. Some medications may require precertification prior to dispensing. However, others may not be available due to policy exclusions and conditions. For a list of excluded drugs, please refer to your prescription drug rider or contact a BlueLincs Member Services representative. The formulary is also on the Prescription Drug page.

BlueLincs will cover prescriptions (as long as they are covered by your plan) that are written by a BlueLincs participating physician or an emergency physician, are FDA (Federal Food and Drug Administration) approved and are obtained at a BlueLincs participating pharmacy.

Your BlueLincs provider directory includes a list of more than 500 participating pharmacies. Take your prescription to one of these pharmacies and show your BlueLincs ID card. Your prescription needs to have been written by a participating BlueLincs physician. You will be required to pay a prescription copayment. It is not necessary to file a claim.

In an emergency or urgent situation out of the service area, you are responsible for paying the full price for the prescription at the time it is filled. Send a copy of your receipt to Member Services with an explanation of why you had to purchase the prescription.

If you have questions about your benefits or the quality of service you have received through BlueLincs HMO, please call BlueLincs Member Services:

• Tulsa Area: (918) 561-9933
• Oklahoma City Area: (405) 841-9777
• Toll-Free: 1-800-580-6202

1. Choose a PCP for yourself and each member of your family.
2. Complete the enclosed application or follow your employer's specific instructions for enrollment. Be sure to indicate your PCP choice on the application.
3. Keep a copy of your BlueLincs application for your records, and submit the originals to your employer.

After your company's group enrollment is complete, you will receive an ID card for yourself and for each covered family member. ID cards are sent directly to your home.