How does the Plan work?

Doctor and BabyIt’s pretty simple: your primary care physician provides most of your care, refers you to specialists and hospitals when needed, and handles all the paperwork and billing on your behalf. Here are some guidelines on how to use your benefits:

1 – How to get a referral for specialty care

There’s very little paperwork that members have to deal with, but getting a referral form from your PCP is one important exception. Referrals help everyone concerned:

  • the specialist knows why you were referred,
  • the specialist can be assured that your PCP has authorized the care, and
  • you are assured that the bill for your visit with the specialist will be paid.

Please remember that it is your responsibility to get referrals before receiving specialty care; referrals cannot be backdated.

Referrals are valid for only those services or diagnoses indicated. All referrals are valid for one year, or for the number of visits indicated, whichever comes first. It’s important that you keep track of the number of visits authorized and how many times you have seen the specialist to whom you’ve been referred.

  • If additional visits are necessary beyond those authorized by your referral, it’s your responsibility to obtain another referral for those additional visits.
  • If the specialist wants to refer you to another specialist or for other services, you need authorization from your PCP.

2 – How to use the Home Delivery Pharmacy Service

Our Home Delivery Pharmacy Service saves over 66% on long-term medications and refills for most prescriptions. Simply ask your doctor to write 90-day prescriptions for your long-term medications—you get a 90-day supply for a price that is the same or even less than you’d pay for a 30-day supply at a retail pharmacy. In fact, generics are free! No driving, no hassles, no charge for postage. Allow 10 days for mailing. Remember that 75% of your medication must already be used before you order refills.

To get started, download the Home Delivery Sign-Up Sheet for New Users and mail the completed form to: Brighton Marine Pharmacy, 77 Warren Street, Boston, MA 02135

3 – How to use the Point of Service option

When you see an out-of-network provider without a referral from your PCP or prior authorization from the Plan (except for medical emergencies), your visit is automatically treated as a POS service and billed accordingly.

Click here for details and costs.

If you have questions we haven’t addressed, please call Member Services for assistance: 1-800-818-8589. If there are other topics that you’d like us to cover here, please let us know.

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