Part 1 – Member Services (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 6 planning to receive. To request an estimate by phone, call the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID card. Blue Cross Blue Shield HMO Blue will give you a cost estimate within two working days of the date your request is received. Blue Cross Blue Shield HMO Blue’s response will include an estimate of the maximum allowed charge and your cost share amount, if there is any, for the proposed covered service, and your health care provider’s network status. For Services Furnished on or After January 1, 2023. In addition to the above cost estimate, as required by federal law, you or your authorized representative may request a real-time estimate of personalized cost sharing information through Blue Cross Blue Shield HMO Blue’s internet-based self-service tool before you receive covered services, including prescription drugs when pharmacy coverage is administered by Blue Cross Blue Shield HMO Blue. This self-service tool will help you to understand how costs for covered services are determined by this health plan. To begin your cost estimate, you can log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org. Just follow the steps to request this cost estimate. You can also call the Blue Cross Blue Shield HMO Blue customer service office to request the same real-time cost estimate information over the telephone. The toll free phone number to call is shown on your ID card. If you need a paper copy of a cost estimate, you can call the Blue Cross Blue Shield HMO Blue customer service office. This information will be made available to you within two business days. For items or services covered under this health plan, Blue Cross Blue Shield HMO Blue’s internet-based self-service tool will include the following information:  Cost-sharing liability at the time of the cost estimate (such as deductible, copayment, and/or coinsurance).  Accumulated amounts such as any accrued deductible and/or out-of-pocket maximum amounts.  Negotiated rates based on network provider payments.  Out-of-network allowed amounts, including the maximum this health plan will pay for an out-of-network provider.  List of items and services covered under this health plan that are subject to bundled payment arrangements, including costs for these bundled covered services.  Notice of plan requirements that apply such as pre-service approval, referrals, pre-admission review or other plan provisions. For each cost estimate, Blue Cross Blue Shield HMO Blue is required to provide a disclosure notice to you that includes the following:  Information disclosing that out-of-network providers may balance bill members for the difference between what the provider bills and the member’s cost share amount (copayment, deductible or coinsurance) and if and when balance billing is permitted under state or federal law.  A statement that your health care provider’s actual charge for your specific covered service may be different from the cost estimate.  A statement that the cost estimate is not a guarantee of coverage.  Information on whether copayment amounts, if any, apply toward your deductible and/or the out-of-pocket maximum amounts. As required by federal law, real-time cost estimates will be available for all covered services. The provisions described above do not apply to you if your health plan is a grandfathered health plan under the Affordable Care Act.