- Member Rights and Responsibilities
As a member, you have certain rights and responsibilities. There’s a summary online we update as needed. If you don’t have access to the web and need a copy of your Certificate of Coverage, Member Guide, Prescription Drug List, Member Policy or Member Rights and Responsibilities, please call the number on the back of your member ID card. Our Member Services department is open Monday through Friday from 8:30 a.m. to 5 p.m.
- Claims and Benefit Information
You can find your new Schedule of Benefits by logging in to your My Health Toolkit® account. Once logged in, select My Plan & Benefits, then Health, then Health Benefits, and select the Benefits Booklets link. This document outlines the specific amount of coverage provided, your copayments, coinsurance, deductible and limitations.
- External Review Procedures
We are committed to quickly resolving your concerns and problems. There are state laws, such as the Health Carrier External Review Act, and federal laws that allow you to ask for an external review in some cases when we deny payment for a claim. These situations have different rules. Please call Member Services to learn your options for an external review.
If you qualify for an external review, we’ll tell you in writing. We’ll also explain what to do.
- Consent for Medical Care at Age 16
Under South Carolina law, any minor who has reached 16 years of age can solely consent to health care decisions, except for surgery. The consent of a parent is not necessary. This is why a completed Authorization To Disclose Protected Health Information to a Third Party form is required for a parent to receive health information about a minor child older than 15 years of age.
To view the form, go to www.BlueOptionSC.com/DisclosePHIForm.
- Women’s Health and Cancer Rights
Do you know that your coverage, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services? These services include all stages of reconstruction and surgery. This includes prostheses and complications from a mastectomy, including lymphedema. Check your policy for more information on this benefit or call the number on the back of your member ID card. Our Member Services department is open Monday through Friday from 8:30 a.m. to 5 p.m.
- Certificate of Coverage and Member Guide
Both your policy and Member Guide are great places to find many important details about your benefits. You can find your policy by logging in to your My Health Toolkit account. Once logged in, select My Plan & Benefits, then Health, then Health Benefits, and select the Benefits Booklets link. You can find the Certificate of Coverage and Member Guide on our website. The Certificate of Coverage and Member Guide will help you understand your benefits and make the most of your coverage.
Here’s some of the information in the Certificate of Coverage and Member Guide:
- How to access primary care, specialty care, behavioral health services, hospital services and much more
- How to get after-hours care, urgent care and emergency care
- How to find care and coverage when you’re outside the service area
- How to submit a claim yourself
- How we coordinate benefits
- How we administer benefits for appropriate services, including our policy on not providing incentives to deny coverage of care or services
- How we decide what new technology we will include as a covered benefit
- How to get information on our quality improvement program
- How to voice a complaint or appeal a decision
- How our privacy practices work
- How to get information about network providers’ qualifications and other provider information
- How your benefits work
- Restrictions on benefits you receive outside South Carolina
- How to get language assistance
- Prescription Drug Information
Get details about medications, price comparisons, your prescription history and up-to-date information on our pharmacy procedures and prescription drug lists.
If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not be counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.
- We leave medical decisions to doctors and patients!
We make decisions about approving services based on whether care is appropriate and agrees with your plan of benefits. We do not reward providers or others for denying coverage or care. And we do not offer financial incentives to anyone to encourage decisions that result in underutilization of care.