Plan Information

From the left navigation of your Member Home page, click on the Benefits Center and Document Center links to view your plan benefits and services. For questions about your coverage, please refer to your subscriber agreement/benefit booklet or call Customer Service.

This list below includes many of the services or categories of services that are not covered (excluded) by most plans for a variety of reasons. These reasons include, but are not limited to, services that are not medically necessary, services that are experimental or investigative, or services that are covered by the government.  For a complete list of covered benefits and exclusions, please refer to your plan benefits by logging in to your Member Home page, checking your subscriber agreement/benefit booklet, or contacting Customer Service.

The following services are covered either partially, or not at all, by Blue Cross:

  • Acupuncture unless covered by a rider or plan design;
  • Autism unless covered by plan design;
  • Charges for blood or drawing, processing, or storage of your own blood;
  • Charges for missed appointments;
  • Completion of claim forms or other administrative charges;
  • Cosmetic procedures except as required by the Women's Health and Cancer Rights Act and Rhode Island law for breast reconstruction following mastectomy;
  • Deductible and copayments;
  • Dental services (Certain limitations apply.);
  • Employment-related injuries;
  • Experimental or investigational services except as required by Rhode Island laws;
  • Extra charges for a private hospital room;
  • Eye exercises and visual training;
  • Eyeglasses for adults unless covered by a rider or plan design;
  • Food or food products, whether or not prescribed except as required by Rhode Island laws;
  • Freezing and storage of blood, sperm, gametes, embryos, or other tissues;
  • Gene therapy and parentage testing;
  • Hearing aids except as required by Rhode Island law, or as covered by a rider;
  • Home­making, companion care, custodial care, day care, or respite care;
  • Illegal drugs;
  • Infant formula, whether or not prescribed except as required by Rhode Island law;
  • Long-term care facilities;
  • Marital counseling;
  • Methadone or other drug maintenance treatment for treating chronic addiction;
  • Personal appearance items or personal comfort items;
  • Recreational therapy, mas­sage therapy, aqua therapy, maintenance therapy, aromatherapy, or biofeedback training;
  • Research studies;
  • Reversal of voluntary sterilization or infertility treatment for an individual that previously had a voluntary sterilization procedure;
  • Routine foot care;
  • Services covered by the government or other sources;
  • Services of Christian Scientist Practitioners;
  • Services of natu­ropaths and homeopaths;
  • Services performed by people or facilities not legally qualified or licensed;
  • Services performed by facilities we have not approved;
  • Services provided by colleges or school health facilities;
  • Services related to surrogate parenting or newborn children of surrogate parents;
  • Services related to employment, education, marriage, adoption, travel, or insurance purposes or when required by similar third parties;
  • Services that are not medi­cally necessary;
  • Services that are not listed in the subscriber agreement/benefit booklet as covered health­care services;
  • Sex transformations or sex therapy, unless covered by plan design;
  • Smoking cessation treatment, except as required by Rhode Island laws and the Affordable Care Act;
  • Telephone consultations; and
  • Weight-loss programs other than preventive obesity screening and counseling services required by the Affordable Care Act.

NOTE: This is a summary of the services that are covered either partially, or not at all, by Blue Cross. It is not a contract. For details about your coverage, including any limitations or exclusions not noted here, please refer to your subscriber agreement/benefit booklet.

To learn more about the costs you may have to pay, log in to your Member Home page. For questions about your coverage, please refer to your subscriber agreement/benefit booklet or call Customer Service.

In addition, we offer an educational video, Healthcare 101, to help you understand the basics of your health plan. This video provides easy-to-understand explanations of key insurance terms like deductible, coinsurance, and out of pocket.

If you need help finding a primary care doctor, other doctor, or a hospital/facility, you can use the Find a Doctor tool or call Customer Service at the number on the back of your member ID card. You can get information such as board certification status, languages spoken by the doctor, and whether the office is wheelchair accessible. If you’re using the Find a Doctor tool, you can even print out directions to the doctor’s office. Please note: If you have a question about a doctor that Customer Service can’t answer right away, they will get back to you with an answer. This includes questions on education, training, residency completed, board certification, and specialty.

While you may not be required to select a primary care provider, these practitioners can assist you in maintaining and monitoring your health and accessing the services of specialty care physicians.

Depending on your plan, you may need a referral from your primary care physician (PCP) to see a specialist, including behavioral health care providers. But even if you don't need a referral, it's a good idea to ask your PCP for a recommendation about which doctor to see. He or she may even be able to set up an appointment for you. Hospital services are usually arranged for you by your physician and may require preauthorization (approval of services in advance).

You can save money by getting specialty care and behavioral healthcare from within the Blue Cross network. Participating providers and facilities are listed on our Find a Doctor tool. If you wish to see an out-of-network provider, Customer Service can help you find a practitioner or facility within a specific geographic area

If you need care after hours or when your primary care physician (PCP) is not available, you should still call your PCP's office. PCPs make arrangements for 24-hour coverage so you can get the care you need even if they're not personally available. When you call, you'll be put in touch with your doctor or the on-call doctor.

Important note: If you are having a medical emergency, call 911, not your doctor! See your Member Handbook for information on emergency care.

When you are covered by Blue Cross, your plan offers specific levels of healthcare benefits wherever you live or travel, across the country and worldwide. Blue Cross participates in the BlueCard Program, which enables you to access the BlueCard national network if you need care when away from home. You can contact Customer Service to verify your benefits and for additional assistance or you can call 1-800-810-Blue (2583). BlueCard provides the name and location of participating BlueCard PPO doctors and hospitals. You can also locate a doctor anytime by visiting:

You will pay the same copayment or deductible that is required when you receive care at home. The doctor will then file the claim for you.

For information about out-of-network coverage and restrictions, please see your Member Handbook or refer to your plan benefits by logging in to your Member Home page, checking your subscriber agreement/benefit booklet, or contacting Customer Service.

If you have prescription drug coverage through Blue Cross, you can find everything you need to manage and maximize your coverage by logging in to your Member Home page and choosing Pharmacy in the left navigation. You can:

  • View your pharmacy benefits and prescription drug history.
  • Order drugs through the mail.
  • Find quantity limits, step therapy, and other restrictions.
  • View the covered drug list (formulary), which changes every April and October.
  • Save money with generic drugs.
  • Start the medical exception process.
  • Determine a drug's common side effects, significant risks, and potential interactions.
  • Find the copayment of any drug to be filled at a retail pharmacy.
  • Find a pharmacy and get door-to-door directions.
  • Get the most frequently requested forms and documents.
  • Know which medications require special paperwork from your provider (specialty drugs).

Our medical director and the Medical Policy Department continually research medical technologies and treatments to decide if they should be covered. Blue Cross also follows guidelines established by the Blue Cross and Blue Shield Association and national guidelines.

As a Blue Cross member, you are a partner in your health — both with your doctor and with Blue Cross. That’s why it’s important to understand your rights and responsibilities. Refer to your Member Handbook for a complete listing of your member rights and responsibilities.

Blue Cross's Grievances and Appeals Unit is here to provide a thorough, timely, and unbiased review of complaints and administrative and medical appeals. The purpose of this process is to ensure that benefits are administered equitably (fairly and equally) according to member contracts, regulatory mandates, accrediting standards, and Blue Cross policies. This process will ensure that objective, equitable outcomes are achieved. To see how to voice a complaint or appeal a decision that negatively affected your coverage, benefits, or your relationship with us, please refer to your Member Handbook.

For your convenience, there are virtually no claim forms for you to file when you seek care from in-network providers and show your member ID card. The provider will process your claims directly with us, so you don't need to handle any paperwork. We then reimburse the provider.

However, if you receive care from a non-network provider, you may have to pay the provider for the service and then file a claim with us for reimbursement. Please refer to your Member Handbook for more detail on filing claims.

If you have any questions about when you may need to file a claim with us, please contact Customer Service.

To receive language assistance, contact Customer Service.

If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Please read the Member Handbook to learn more about the tools and information available to help you manage your condition and improve your health.

Care Coordination provides support for members with chronic (for example, asthma or diabetes), complex, or catastrophic (very serious) conditions. Please see the Member Handbook to learn more about this program.

The Quality Management (QM) Program ensures that our members experience the best health outcomes possible when receiving physical and behavioral healthcare services. This includes collaborating with our provider network to focus on the safety of our members’ care. By continually working to improve quality, the QM Program establishes high standards of evidence-based medical practice in the community, prioritizes member health and safety, and works to improve member and provider satisfaction. This process helps ensure our members receive high-quality care that improves their health. It also positively impacts the health of our community. The Blue Cross QM Program goals are to:

  • Perform quality improvement and assurance activities in alignment with our corporate mission, goals, and strategies.
  • Improve quality, safety, and coordination of care for our members receiving physical and behavioral healthcare services.
  • Integrate physical and behavioral healthcare to improve the quality of care delivered to our members.
  • Continuously promote and monitor evidence-based best medical practice across our network of providers.
  • Collaborate with community partners to achieve improved care for all Blue Cross members.
  • Improve the quality of member and provider engagement and satisfaction with the health plan, including access to care.
  • Identify our members’ varied cultural and linguistic needs to offer a diverse range of services, which provide meaningfully improved care to our members and support our providers’ care for members.
  • Improve the cost, quality, and efficiency of service delivered to members and providers.

Members can view the Goals of the QM Program and our progress toward meeting these goals in the 2013 QM Program Evaluation.

Blue Cross is committed to providing integrated, high-quality services while enhancing the safety of our members and providers. Member safety initiatives proactively identify and evaluate issues related to patient safety for both physical and behavioral healthcare. Blue Cross helps foster an environment that allows all providers (of physical and behavioral healthcare) to improve the safety of their practices and the quality and coordination of care they deliver. BCBSRI has implemented several initiatives to improve the safety and care our members receive, including our:

  • Hospital Quality Program, which helps improve the quality, safety, and efficiency of care provided in local hospitals
  • Transitions of Care Program, which helps patients safely transition from the hospital to home and reduces hospital readmissions
  • Patient-Centered Medical Home initiative
  • Process for reviewing quality of care complaints, which can be found in our Member Handbook

You have the right to view or get copies of your personal health information used by our health plan to make decisions about payment for your healthcare. To view or copy your records, you must submit your request to us in writing. We will provide a release of information form for you to complete and send to us with your request. Our Notice of Privacy Practices provides detailed information on your privacy rights, including how to submit a request to us in writing.

Blue Cross employees and agents protect the privacy and confidentiality of our members' healthcare information through administrative, technical, and physical safeguards. We maintain, use, and disclose confidential health information as permitted or required by applicable state and federal laws, such as the Rhode Island Confidentiality of Health Care Communications and Information Act, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Privacy and Security Regulations of HIPAA require us to implement specific safeguards to protect the privacy of our members’ health information, in both printed and electronic formats. You can learn more about these safeguards in the Member Handbook, in our Protecting Your Information presentation, or the Notice of Privacy Practices.

Did you know that you may be required to get prior approval from Blue Cross for certain medical services or procedures? This is called preauthorization and it helps you:

  • Find out if you’re covered by your benefits before you have your scheduled procedure.
  • Save money and avoid extra costs.
  • Estimate your out-of-pocket costs before you get your service.
  • Avoid unnecessary services.

Learn more about the preauthorization process in your Member Handbook.

All utilization review decisions are based only on appropriateness of care, service, existence of coverage, and setting of the covered service. Please note:

  • We do not use financial incentives in conjunction with our Utilization Management Program.
  • We do not reward doctors who conduct utilization review for issuing denials of coverage or service.
  • We do not offer financial incentives to utilization management decision makers that encourage decisions resulting in underutilization.

To request preauthorization or other utilization management matters, please call the Utilization Management Department at (401) 272-5670 or 1-800-635-2477 (outside of Rhode Island only) during normal business hours: Monday through Friday, 8:00 a.m. to 4:30 p.m. TTY/TDD (Telecommunications Device for the Deaf) services are available by calling 1-888-252-5051 during normal business hours. If you need interpreter services to discuss utilization management matters, please ask one of our representatives about using an interpreter. After hours, if it is a non-urgent matter, you will be directed to leave a brief message with your name and number. Your call will be returned the next business day.

As part of our Utilization Management Program, members have the right to appeal our review decisions. You can find information about our Utilization Management Program in your Member Handbook.