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2022 Benefit Information for Members

View and download information for your 2022 plan through December 31, 2022.

BlueJourney HMO

The Annual Notice of Change (ANOC) is a document sent out to members in October of each year. It lists all benefit and prescription changes taking place in the upcoming plan year.

The Evidence of Coverage (EOC) document outlines all the information you need to know about your Medicare Advantage plan. That includes benefits and copays, important phone numbers and resources, what we pay and what you pay, and much more!

BlueJourney PPO

The Annual Notice of Change (ANOC) is a document sent out to members in October of each year. It lists all benefit and prescription changes taking place in the upcoming plan year.

The Evidence of Coverage (EOC) document outlines all the information you need to know about your Medicare Advantage plan. That includes benefits and copays, important phone numbers and resources, what we pay and what you pay, and much more!

Capital Blue Cross | WellSpan Health HMO

  • Summary of Benefits—A side-by-side summary of our three BlueJourney PPO plans.
  • Evidence of Coverage - Inspire—The Evidence of Coverage (EOC) document outlines all the information you need to know about your Medicare Advantage plan. That includes benefits and copays, important phone numbers and resources, what we pay and what you pay, and much more!
  • Out-of-Network Coverage Rule—Explains how to get care from an out-of-network doctor.
  • Member Claim Form—A printable form you need to submit to us for reimbursement of a service.
  • Preauthorization Form—The form needed to request authorization in advance for a certain service or procedure.

Capital Blue Cross | WellSpan Health PPO

  • Summary of Benefits—A side-by-side summary of our two Capital Blue Cross | WellSpan Health PPO plans.

The Evidence of Coverage (EOC) document outlines all the information you need to know about your Medicare Advantage plan. That includes benefits and copays, important phone numbers and resources, what we pay and what you pay, and much more!

Reimbursement, Enrollment and Representation Forms

Claims and Reimbursement

Enrollment

Appoint a Representative to Discuss Your Options with us

Print, complete and send back this form to allow a family member or friend to communicate with us on your behalf. You can also call the Member Services number on your ID card and request a copy be mailed to you.

Appeals and Grievance

Appoint a Representative to assist with your Appeal

Let someone file a grievance (complaint), ask for coverage or make an appeal for you.

This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form.

National and Local Medicare Coverage Information

The Centers for Medicare and Medicaid Services (CMS) works to expand and improve coverage for Medicare participants. There are National Coverage Determinations (NCD’s) and Local Coverage Determinations (LCD’s) issued throughout the year that expand health care coverage for various services. Listed below are some of those new coverage determinations.

Quality Improvement Organization

You should contact the Quality Improvement Organization if you have a complaint about the quality of care you have received. For example, you can contact the Quality Improvement Organization if you were given the wrong medication or if you were given medications that interact in a negative way.

Livanta (Pennsylvania’s Quality Improvement Organization)

Contact

Phone: 888.396.4646 (TTY: 888.985.2660)

Fax: 1.833.868.4057

Visit the Livanta website.

Write by mail:

Livanta BFCC-QIO Program

10820 Guilford Road, Suite 202 
Annapolis Junction, MD 20701

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Coverage in a Disaster

Dental, Vision and Hearing Benefits

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Updated October 1, 2021

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