Part 4 – Utilization Review Requirements (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 28 log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org. Just follow the steps to check your benefits.  Infertility treatment.  Certain prescription drugs that you buy from a pharmacy or that are administered to you by a non-pharmacy health care provider during a covered visit. For example, you receive an injection or an infusion of a drug in a physician’s office or in a hospital outpatient setting. A key part of this pre-service approval process is the step therapy program. It helps your health care provider provide you with the appropriate drug treatment. To find out if your prescription drug requires a prior approval from Blue Cross Blue Shield HMO Blue, you can call the Blue Cross Blue Shield HMO Blue customer service office. From time to time, Blue Cross Blue Shield HMO Blue may change the list of health care services and supplies that require a prior approval. When a material change is made to these requirements, Blue Cross Blue Shield HMO Blue will let the subscriber (or the subscriber’s group on your behalf when you are enrolled in this health plan as a group member) know about the change at least 60 days before the change becomes effective. Missing Information In some cases, Blue Cross Blue Shield HMO Blue will need more information or records to determine if your proposed health care services or supplies should be covered as medically necessary to treat your condition. For example, Blue Cross Blue Shield HMO Blue may ask for the results of a face-to-face clinical evaluation or of a second opinion. If Blue Cross Blue Shield HMO Blue does need more information, Blue Cross Blue Shield HMO Blue will ask for this missing information or records within 15 calendar days of the date that it received your health care provider’s request for pre-service approval. The information or records that Blue Cross Blue Shield HMO Blue asks for must be provided to Blue Cross Blue Shield HMO Blue within 45 calendar days of the request. If this information or these records are not provided to Blue Cross Blue Shield HMO Blue within these 45 calendar days, your proposed coverage will be denied. If Blue Cross Blue Shield HMO Blue receives this information or these records within this time frame, Blue Cross Blue Shield HMO Blue will make a decision within two working days of the date it is received. Coverage Approval If through the pre-service review Blue Cross Blue Shield HMO Blue determines that your proposed health care service, supply, or course of treatment should be covered as medically necessary for your condition, Blue Cross Blue Shield HMO Blue will call the health care provider. Blue Cross Blue Shield HMO Blue will make this phone call within 24 hours of the time the decision is made to let the health care provider know of the coverage approval status of the review. Then, within two working days of that phone call, Blue Cross Blue Shield HMO Blue will send a written (or electronic) notice to you and to the health care provider. This notice will let you know (and confirm) that your coverage was approved. Coverage Denial If through the pre-service review Blue Cross Blue Shield HMO Blue determines that your proposed health care service, supply, or course of treatment should not be covered as medically necessary for your condition, Blue Cross Blue Shield HMO Blue will call the health care provider. Blue Cross Blue Shield HMO Blue will make this phone call within 24 hours of the time the decision is made to let the health care provider know that the coverage was denied and to discuss alternative treatment. Then, within one working day of that phone call, Blue Cross Blue Shield HMO Blue will send a written (or electronic) notice to you and to the health care provider. This notice will explain Blue Cross Blue Shield HMO Blue’s coverage decision. This notice will include: information related to the details about your coverage denial; the reasons that Blue Cross Blue Shield HMO Blue has denied the request and the applicable terms of