Questions and Answers SimplyBlue – New HMO Product

Questions and Answers SimplyBlue ? New HMO Product

This fall, we will introduce a new HMO product to small employer groups called SimplyBlue. The first effective date will be January 1, 2018.

What is SimplyBlue? ? SimplyBlue is an HMO product with predictable copay, coinsurance, and deductible cost share amounts. ? Although members are assigned a primary care physician, they can go to any in-network primary care physician for care. ? Referrals to specialists are not required. However, the member must be sure to select a specialist who is in-network for the SimplyBlue product ? Authorizations are required for inpatient and/or outpatient services

What is the effective date for SimplyBlue? Small group employers can purchase SimplyBlue for their employees starting October 1, 2017, for effective dates begining January 1, 2018.

What provider network supports SimplyBlue? SimplyBlue uses a sub-group of our BlueCare? HMO (Health Options, Inc.) primary care physicians and specialists network. Physicians invited to be SimplyBlue providers are selected based on several factors including quality of care, efficiency, range of service, and hospital affiliation.

The SimplyBlue hospital network is similar to the hospital network for BlueCare HMO (Health Options, Inc.).

All BlueCare HMO providers in the counties where the new product is available can see SimplyBlue members unless they receive a letter from Florida Blue notifying them that they are not participating with SimplyBlue.

Where is the SimplyBlue product available? We will offer it to small group employers in Orange, Seminole, Osceola, Hillsborough, Pinellas, Pasco, Miami-Dade, Broward, and Palm Beach counties.

How will I know if I participate in SimplyBlue? If you participate in the BlueCare HMO (Health Options, Inc.) and do not receive an exclusion notice from us, then you are an in-network provider for SimplyBlue members.

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How can I identify SimplyBlue members? The member ID card shows the product name in the upper right corner ? SimplyBlue. The alpha prefix is FSO.

What specialists can SimplyBlue members see? SimplyBlue members must visit specialists who are in the network for SimplyBlue. Out-ofnetwork benefits are not included, except for emergency services. If a SimplyBlue member visits a provider who does not participate in the SimplyBlue network, they may have to pay the full cost of the visit.

How will I know if a specialist is in-network for SimplyBlue? Please check our online provider directory at and select Find a Doctor. Remember to include the name of the product, SimplyBlue, when checking for an in-network specialist or provider.

What pharmacies can SimplyBlue members use for prescriptions? ? SimplyBlue uses certain preferred pharmacies that include Publix, Walgreens, Walmart, and Winn-Dixie. Members pay less when they use preferred pharmacies to fill prescriptions. ? Other national and regional chains, plus many independent pharmacies are in the network, but they are standard pharmacies, and the member pays more when they use them. ? Important: The SimplyBlue network does not include CVS-owned pharmacies including Target and Navarro. If a member uses a CVS pharmacy, they will have to pay the entire amount for prescriptions.

How is SimplyBlue different from BlueCare HMO? ? SimplyBlue includes a smaller primary care physician and specialist network. ? SimplyBlue uses the ValueScript pharmacy formulary

How do I verify eligibility and benefits, and obtain referrals and authorizations for SimplyBlue members? You can verify eligibility and benefits electronically through Availity?1 at . Referrals are not required for your SimplyBlue patients. However, authorizations are required for inpatient and outpatient services. Please check the Utilization Management section of the Manual for Physicians and Providers on our website at ; select Providers (top of the page), Tools & Resources, and then Provider Manual.

What if I don't request an authorization for services? If an authorization is required and one is not on file, then the services are not covered.

How can I verify a SimplyBlue patient's assigned primary care physician? You can verify a patient's assigned primary care physician through Availity at .

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How can I determine which members are assigned to the participating primary care physicians in my practice? Participating primary care physicians will get a list of assigned members through Availity at that identifies new members. Through Availity, you can also use the helpful Quality and Efficiency Reporting Tool (QERP) data to identify cost, quality, utilization, and administrative improvement opportunities for your practice. What laboratory/pathology provider is in-network for SimplyBlue? Quest Diagnostics is our preferred in-network clinical lab provider. Dermpath Diagnostics is our in-network preferred lab for anatomical pathology services. Important: Always refer members to a Quest Diagnostic or Dermpath Diagnostics clinical lab for services whenever possible to keep their out-of-pocket costs as low as possible. SimplyBlue members should use Quest and/or Dermpath Diagnostics for lab services or they have to pay the full amount for the services. What about in-office lab services? Only certain lab services performed in a SimplyBlue primary care physician or specialist's office are eligible for payment. Please refer to the list of lab services in the Standing Authorizations section of the Manual for Physicians and Providers on our website at . These are the only lab services that are eligible for payment when performed in the office by a participating primary care physician or specialist. Where can I find more information about SimplyBlue? Please refer to the Manual for Physicians and Providers on our website at . If you have questions about this information, call the Provider Contact Center at (800) 7272227.

1Availity, LLC is a multi-payer, joint venture company. For more information or to register, visit Availity's website at .

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