- How do I obtain care away from home?
- What if I run out of medication while out of town?
- What is a formulary or preferred drug list?
- May I appeal a denied claim?
- Who can discuss my health insurance information?
How do I obtain care away from home?
Always carry your Bluegrass Family Health member identification
card when you leave home. Benefits are provided for treatment for urgent and emergency care
when you are out of Bluegrass Family Health’s service area. Please refer to your Certificate
of Coverage (COC) for definitions of urgent and emergency care. Your cost sharing
(co-payment, co-insurance) will be based on the type of facility where you seek care.
Urgent Care centers are free standing facilities. Some hospitals have Urgent Care signs
posted, but may actually bill as an Emergency Room. If the service is billed as an Emergency
Room visit, you will be responsible for an Emergency Room Co-payment.
Follow-up care is NOT COVERED at your in-network benefit if you use a non
participating provider. Check with Customer Service or visit the web site at
www.bgfh.com for provider participation information and
to see if a prior authorization is required. Whenever possible, you should attain follow-up
care within the BFH provider network.
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What if I run out of medication while out of town?
Prescriptions can be filled away from home through many national
pharmacy chains such as Wal-Mart, CVS, Rite-Aid, Kroger or Walgreens.
If you cannot find a participating pharmacy, you can pay for the prescription and submit
a request for reimbursement to the Pharmacy Services Department at Bluegrass Family Health.
Be sure to keep your receipts and prescription information. Prescriptions will be reimbursed
according to the benefit of your plan.
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What is a formulary or preferred drug list?
A formulary or Preferred Drug List (PDL) is a listing of
medications covered under your Bluegrass Family Health, Inc. (BFH) pharmacy benefit. Not all
drugs will be listed on the formulary. Generic drugs in most cases are covered at a 1st Tier
copay. Exceptions are generic drugs manufactured by one generic company; these are commonly
known as "branded generics." If your medication is considered a "brand name drug" and is not
listed on the formulary (PDL), in most cases it will be covered at a 3rd Tier copay. Other
drugs may not be covered as they are considered a benefit exclusion. Examples of excluded
drugs are medication for weight loss, smoking cessation, lifestyle drugs, hair loss, and
drugs used for cosmetic conditions.
If you are not sure if your medication is an excluded drug please ask your Doctor or
Pharmacist. You may also call Pharmacy Services at Bluegrass Family Health at
(877) 205-6308 or (859) 335-3755 from 8:00 am to 6:00 pm ET or contact us via email at
pharmacy@bgfh.com.
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May I appeal a denied claim?
Bluegrass Family Health members have the right to appeal denied
claims if they feel the decision was made in error. Appeals can also be made on behalf of a
member by the member's doctor, lawyer or a person with power of attorney in health care
matters. A health care provider, such as a hospital or ambulance service, can appeal a
denial as well.
You must notify Bluegrass Family Health in writing that you are appealing the decision
within sixty days of the day you receive a denied claim. Include in your appeal any
information you think supports your appeal. Then mail your appeal to:
Appeals Coordinator
Bluegrass Family Health, Inc.
651 Perimeter Drive, Suite 300
Lexington, KY 40517
A decision on your appeal will be made within thirty days of the date Bluegrass Family Health
receives your appeal. A written copy of that decision will be mailed to you and anyone
who has appealed on your behalf.
For more information see Member Inquiries and Appeals.
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Who can discuss my health insurance information?
 Your individual health information is protected under the
Health Insurance Portability and Accountability Act (HIPAA), which limits what others may
know about your health insurance and claims. You should have received Bluegrass Family
Health’s Privacy Notice; if you have not, please contact Customer Service.
If you wish to allow your spouse, a parent or anyone else to discuss your claims and
personal health information, you can submit a Use and Disclosure Authorization Form,
available on our website or by calling Customer Service. This form remains effective to the
date you specify, up to two years. You can limit the type of records your designee may
access and you can have the authorization terminated at your discretion. This form allows
your designee to help you with any billing, eligibility or other issues related to your
membership with Bluegrass Family Health.
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