Page 7 - Sumitomo EE Guide 06-20 Final English

BENEFITS

MEDICAL INSURANCE

BLUE SHIELD | HMO
California Residents Only
With the Blue Shield Health Maintenance Organization (HMO) plan, you must choose a primary care physician (PCP) within the
Access+ HMO network. All of your care must be directed through your PCP or medical group. Any specialty care you need will be
coordinated through your PCP and will generally require a referral or authorization. You will receive benefits only if you use the
doctors, clinics and hospitals that belong to the medical group in which you are enrolled, except in the case of an emergency. This
plan allows you to receive specialist referrals from your PCP or you may self-refer to an Access+ Specialist within your PCP’s
medical group for a higher copay.

BLUE SHIELD | PPO MEDICAL PLAN
California and Non-California Residents
The Blue Shield Preferred Provider Organization (PPO) plan allows you to direct your own care. You are not limited to the
physicians within the network and you may self-refer to specialists. If you receive care from a physician who is a member of the
network, a greater percentage of the entire cost will be paid by the insurance plan. You may also obtain services using a non‐
network provider; however, you will be responsible for the difference between the covered amount and the actual charges and
you may be responsible for filing claims.

LOCATING A MEDICAL PROVIDER

If you reside in California: If you reside outside of California:
• For both HMO and PPO providers, visit • Go to www.bscaplan.com/fpbmeq and scroll
www.bscaplan.com/jtaxml and scroll down to down to “Find a Doctor”
“Find a Doctor” • Call Member Service (855) 599-2650
• Call Member Services (855) 599-2650

HEALTH ADVOCATE
Health Advocate is a program that provides you with experienced help when dealing with benefit related issues. Their team
includes highly trained registered nurses, backed by a staff of medical directors and administrative experts. When you call Health
Advocate for assistance you are assigned a Personal Health Advocate who takes responsibility for helping you to resolve problems.

Here are a few of the ways that they help:
• They help you get your claims and/or billing issues resolved
• They help you get answers to your medical questions about test results, treatment plans, and medications recommended by
your doctor
• They work with our insurance carriers to help obtain appropriate approval for services when necessary
• They assist in communications between your doctors and the insurance companies
• They help you locate and contact the best doctors, dentists, and treatment facilities in your networks
• They share unbiased health information when you need to make an informed decision about your care

CONTACTING HEALTH ADVOCATE

Call (866) 695-8622 or send an email to answers@healthadvocate.com

7