Vascular endothelial growth factor (VEGF) has been implicated in the pathogenesis of a variety of ocular vascular conditions. The macula, with the fovea at its center, has the highest photoreceptor concentration and is where visual detail is discerned. The anti-VEGF agent’s brolucizumab-dbll (Beovu®), ranibizumab (Lucentis™), ranibizumab-nuna (ByoovizTM) – biosimilar to Lucentis, ranibizumab injection ocular implant (SusvimoTM), bevacizumab (Avastin®), pegaptanib (Macugen®) andaflibercept (Eylea ™), and faricimab-svoa (VabysmoTM) are used to treat certain ocular disorders and are given by intravitreal injection.
Symptomatic vitreomacular adhesion (VMA) occurs when the vitreous (jelly-like substance inside the eye) has persistent adhesion to the macula. Symptomatic VMA symptoms such as distorted or decreased vision are a result of this persistent adhesion. If the disease progresses, the symptoms can worsen and may result in central vision defect and loss of vision. Ocriplasmin (Jetrea®), a proteolytic enzyme, is a single intravitreal injection indicated for the treatment of symptomatic VMA. It breaks down proteins in the eye responsible for VMA.
Aflibercept (Eylea) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:
Reauthorization Criteria
The use of aflibercept (Eylea) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J0178 |
|
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|
Bevacizumab (Avastin) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:
The use of bevacizumab (Avastin) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J9035 |
C9257 |
|
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Brolucizumab-dbll (Beovu) may be considered medically necessary for the treatment of individuals with:
Reauthorization Criteria
The use of brolucizumab-dbll (Beovu) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J0179 |
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A single intravitreal injection of ocriplasmin (Jetrea) may be considered medically necessary for treatment of an eye* with symptomatic VMA when ALL of the following criteria are met:
*NOTE: For treatment of bilateral VMA, a waiting period of at least 7 days is recommended before treatment of the contralateral eye.
Repeat intravitreal injection of ocriplasmin (Jetrea) in the affected eye is considered experimental/investigational.
The use of ocriplasmin (Jetrea) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J7316 |
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Pegaptanib (Macugen) may be considered medically necessary for the treatment of individuals with:
Reauthorization Criteria
The use of pegaptanib (Macugen) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J2503 |
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Ranibizumab (Lucentis) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:
Reauthorization Criteria
The use of ranibizumab (Lucentis) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J2778 |
|
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Ranibizumab-nuna (Byooviz) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:
Reauthorization Criteria
The use of ranibizumab-nuna (Byooviz) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
Q5124 |
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|
Ranibizumab (Susvimo) intravitreal injection via ocular implant may be considered medically necessary for the treatment of individuals with:
Reauthorization Criteria
The use of ranibizumab (Susvimo) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J2779 |
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Faricimab-svoa (Vabysmo) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:
Reauthorization Criteria
The use of faricimab-svoa (Vabysmo) for any other indication is considered experimental and investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
67028 |
J2777 |
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NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
C9257 |
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Refer to Medical Policy Bulletin, I-86 Bevacizumab (Avastin) and Bevacizumab Biosimilars, for additional information on oncologic (cancer) indications for bevacizumab (Avastin).
Covered Diagnosis Codes for Procedure Codes J0179 J2503 and J2779
H35.3210 |
H35.3211 |
H35.3212 |
H35.3213 |
H35.3220 |
H35.3221 |
H35.3222 |
H35.3223 |
H35.3230 |
H35.3231 |
H35.3232 |
H35.3233 |
H35.3290 |
H35.3291 |
H35.3292 |
H35.3293 |
|
|
|
|
|
Covered Diagnosis Codes for Procedure Code J0178
E08.311 |
E08.319 |
E08.3211 |
E08.3212 |
E08.3213 |
E08.3219 |
E08.3291 |
E08.3292 |
E08.3293 |
E08.3299 |
E08.3311 |
E08.3312 |
E08.3313 |
E08.3319 |
E08.3391 |
E08.3392 |
E08.3393 |
E08.3399 |
E08.3411 |
E08.3412 |
E08.3413 |
E08.3419 |
E08.3491 |
E08.3492 |
E08.3493 |
E08.3499 |
E08.3511 |
E08.3512 |
E08.3513 |
E08.3519 |
E08.3591 |
E08.3592 |
E08.3593 |
E08.3599 |
E08.37X1 |
E08.37X2 |
E08.37X3 |
E08.37X9 |
E09.311 |
E09.319 |
E09.3211 |
E09.3212 |
E09.3213 |
E09.3219 |
E09.3291 |
E09.3292 |
E09.3293 |
E09.3299 |
E09.3311 |
E09.3312 |
E09.3313 |
E09.3319 |
E09.3391 |
E09.3392 |
E09.3393 |
E09.3399 |
E09.3411 |
E09.3412 |
E09.3413 |
E09.3419 |
E09.3491 |
E09.3492 |
E09.3493 |
E09.3499 |
E09.3511 |
E09.3512 |
E09.3513 |
E09.3519 |
E09.3591 |
E09.3592 |
E09.3593 |
E09.3599 |
E09.37X1 |
E09.37X2 |
E09.37X3 |
E09.37X9 |
E10.311 |
E10.319 |
E10.3211 |
E10.3212 |
E10.3213 |
E10.3219 |
E10.3291 |
E10.3292 |
E10.3293 |
E10.3299 |
E10.3311 |
E10.3312 |
E10.3313 |
E10.3319 |
E10.3391 |
E10.3392 |
E10.3393 |
E10.3399 |
E10.3411 |
E10.3412 |
E10.3413 |
E10.3419 |
E10.3491 |
E10.3492 |
E10.3493 |
E10.3499 |
E10.3511 |
E10.3512 |
E10.3513 |
E10.3519 |
E10.3591 |
E10.3592 |
E10.3593 |
E10.3599 |
E10.37X1 |
E10.37X2 |
E10.37X3 |
E10.37X9 |
E11.311 |
E11.319 |
E11.3211 |
E11.3212 |
E11.3213 |
E11.3219 |
E11.3291 |
E11.3292 |
E11.3293 |
E11.3299 |
E11.3311 |
E11.3312 |
E11.3313 |
E11.3319 |
E11.3391 |
E11.3392 |
E11.3393 |
E11.3399 |
E11.3411 |
E11.3412 |
E11.3413 |
E11.3419 |
E11.3491 |
E11.3492 |
E11.3493 |
E11.3499 |
E11.3511 |
E11.3512 |
E11.3513 |
E11.3519 |
E11.3551 |
E11.3552 |
E11.3553 |
E11.3559 |
E11.3591 |
E11.3592 |
E11.3593 |
E11.3599 |
E11.37X1 |
E11.37X2 |
E11.37X3 |
E11.37X9 |
E13.311 |
E13.319 |
E13.3211 |
E13.3212 |
E13.3213 |
E13.3219 |
E13.3291 |
E13.3292 |
E13.3293 |
E13.3299 |
E13.3311 |
E13.3312 |
E13.3313 |
E13.3319 |
E13.3391 |
E13.3392 |
E13.3393 |
E13.3399 |
E13.3411 |
E13.3412 |
E13.3413 |
E13.3419 |
E13.3491 |
E13.3492 |
E13.3493 |
E13.3499 |
E13.3511 |
E13.3512 |
E13.3513 |
E13.3519 |
E13.3591 |
E13.3592 |
E13.3593 |
E13.3599 |
E13.37X1 |
E13.37X2 |
E13.37X3 |
E13.37X9 |
H34.8110 |
H34.8120 |
H34.8130 |
H34.8190 |
H34.8310 |
H34.8320 |
H34.8330 |
H34.8390 |
H35.3210 |
H35.3211 |
H35.3212 |
H35.3213 |
H35.3220 |
H35.3221 |
H35.3222 |
H35.3223 |
H35.3230 |
H35.3231 |
H35.3232 |
H35.3233 |
H35.3290 |
H35.3291 |
H35.3292 |
H35.3293 |
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|
|
|
|
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Covered Diagnosis Codes for Procedure Code J2778
E08.311 |
E08.319 |
E08.3211 |
E08.3212 |
E08.3213 |
E08.3219 |
E08.3291 |
E08.3292 |
E08.3293 |
E08.3299 |
E08.3311 |
E08.3312 |
E08.3313 |
E08.3319 |
E08.3391 |
E08.3392 |
E08.3393 |
E08.3399 |
E08.3411 |
E08.3412 |
E08.3413 |
E08.3419 |
E08.3491 |
E08.3492 |
E08.3493 |
E08.3499 |
E08.3511 |
E08.3512 |
E08.3513 |
E08.3519 |
E08.3551 |
E08.3552 |
E08.3553 |
E08.3559 |
E08.3591 |
E08.3592 |
E08.3593 |
E08.3599 |
E08.37X1 |
E08.37X2 |
E08.37X3 |
E08.37X9 |
E09.311 |
E09.319 |
E09.3211 |
E09.3212 |
E09.3213 |
E09.3219 |
E09.3291 |
E09.3292 |
E09.3293 |
E09.3299 |
E09.3311 |
E09.3312 |
E09.3313 |
E09.3319 |
E09.3391 |
E09.3392 |
E09.3393 |
E09.3399 |
E09.3411 |
E09.3412 |
E09.3413 |
E09.3419 |
E09.3491 |
E09.3492 |
E09.3493 |
E09.3499 |
E09.3511 |
E09.3512 |
E09.3513 |
E09.3519 |
E09.3551 |
E09.3552 |
E09.3553 |
E09.3559 |
E09.3591 |
E09.3592 |
E09.3593 |
E09.3599 |
E09.37X1 |
E09.37X2 |
E09.37X3 |
E09.37X9 |
E10.311 |
E10.319 |
E10.3211 |
E10.3212 |
E10.3213 |
E10.3219 |
E10.3291 |
E10.3292 |
E10.3293 |
E10.3299 |
E10.3311 |
E10.3312 |
E10.3313 |
E10.3319 |
E10.3391 |
E10.3392 |
E10.3393 |
E10.3399 |
E10.3411 |
E10.3412 |
E10.3413 |
E10.3419 |
E10.3491 |
E10.3492 |
E10.3493 |
E10.3499 |
E10.3511 |
E10.3512 |
E10.3513 |
E10.3519 |
E10.3551 |
E10.3552 |
E10.3553 |
E10.3559 |
E10.3591 |
E10.3592 |
E10.3593 |
E10.3599 |
E10.37X1 |
E10.37X2 |
E10.37X3 |
E10.37X9 |
E11.311 |
E11.319 |
E11.3211 |
E11.3212 |
E11.3213 |
E11.3219 |
E11.3291 |
E11.3292 |
E11.3293 |
E11.3299 |
E11.3311 |
E11.3312 |
E11.3313 |
E11.3319 |
E11.3391 |
E11.3392 |
E11.3393 |
E11.3399 |
E11.3411 |
E11.3412 |
E11.3413 |
E11.3419 |
E11.3491 |
E11.3492 |
E11.3493 |
E11.3499 |
E11.3511 |
E11.3512 |
E11.3513 |
E11.3519 |
E11.3551 |
E11.3552 |
E11.3553 |
E11.3559 |
E11.3591 |
E11.3592 |
E11.3593 |
E11.3599 |
E11.37X1 |
E11.37X2 |
E11.37X3 |
E11.37X9 |
E13.311 |
E13.319 |
E13.3211 |
E13.3212 |
E13.3213 |
E13.3219 |
E13.3291 |
E13.3292 |
E13.3293 |
E13.3299 |
E13.3311 |
E13.3312 |
E13.3313 |
E13.3319 |
E13.3391 |
E13.3392 |
E13.3393 |
E13.3399 |
E13.3411 |
E13.3412 |
E13.3413 |
E13.3419 |
E13.3491 |
E13.3492 |
E13.3493 |
E13.3499 |
E13.3511 |
E13.3512 |
E13.3513 |
E13.3519 |
E13.3551 |
E13.3552 |
E13.3553 |
E13.3559 |
E13.3591 |
E13.3592 |
E13.3593 |
E13.3599 |
E13.37X1 |
E13.37X2 |
E13.37X3 |
E13.37X9 |
H34.8110 |
H34.8111 |
H34.8120 |
H34.8121 |
H34.8130 |
H34.8131 |
H34.8190 |
H34.8191 |
H34.8310 |
H34.8311 |
H34.8320 |
H34.8321 |
H34.8330 |
H34.8331 |
H34.8390 |
H34.8391 |
H35.051 |
H35.052 |
H35.053 |
H35.059 |
H35.3210 |
H35.3211 |
H35.3212 |
H35.3213 |
H35.3220 |
H35.3221 |
H35.3222 |
H35.3223 |
H35.3230 |
H35.3231 |
H35.3232 |
H35.3233 |
H35.3290 |
H35.3291 |
H35.3292 |
H35.3293 |
H44.20 |
H44.21 |
H44.22 |
H44.23 |
H44.2A1 |
H44.2A2 |
H44.2A3 |
H44.2A9 |
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Covered Diagnosis Codes for Procedure Code J7316
H43.821 |
H43.822 |
H43.823 |
H43.829 |
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Covered Diagnosis Codes for Procedure Code J9035 and C9257
B39.4 |
B39.5 |
B39.9 |
E08.311 |
E08.319 |
E08.3211 |
E08.3212 |
E08.3213 |
E08.3219 |
E08.3291 |
E08.3292 |
E08.3293 |
E08.3299 |
E08.3311 |
E08.3312 |
E08.3313 |
E08.3319 |
E08.3391 |
E08.3392 |
E08.3393 |
E08.3399 |
E08.3411 |
E08.3412 |
E08.3413 |
E08.3419 |
E08.3491 |
E08.3492 |
E08.3493 |
E08.3499 |
E08.3511 |
E08.3512 |
E08.3513 |
E08.3519 |
E08.3521 |
E08.3522 |
E08.3523 |
E08.3529 |
E08.3531 |
E08.3532 |
E08.3533 |
E08.3539 |
E08.3541 |
E08.3542 |
E08.3543 |
E08.3549 |
E08.3551 |
E08.3552 |
E08.3553 |
E08.3559 |
E08.3591 |
E08.3592 |
E08.3593 |
E08.3599 |
E08.37X1 |
E08.37X2 |
E08.37X3 |
E08.37X9 |
E09.311 |
E09.319 |
E09.3211 |
E09.3212 |
E09.3213 |
E09.3219 |
E09.3291 |
E09.3292 |
E09.3293 |
E09.3299 |
E09.3311 |
E09.3312 |
E09.3313 |
E09.3319 |
E09.3391 |
E09.3392 |
E09.3393 |
E09.3399 |
E09.3411 |
E09.3412 |
E09.3413 |
E09.3419 |
E09.3491 |
E09.3492 |
E09.3493 |
E09.3499 |
E09.3511 |
E09.3512 |
E09.3513 |
E09.3519 |
E09.3521 |
E09.3522 |
E09.3523 |
E09.3529 |
E09.3531 |
E09.3532 |
E09.3533 |
E09.3539 |
E09.3551 |
E09.3552 |
E09.3553 |
E09.3559 |
E09.3591 |
E09.3592 |
E09.3593 |
E09.3599 |
E09.37X1 |
E09.37X2 |
E09.37X3 |
E09.37X9 |
E10.311 |
E10.319 |
E10.3211 |
E10.3212 |
E10.3213 |
E10.3219 |
E10.3291 |
E10.3292 |
E10.3293 |
E10.3299 |
E10.3311 |
E10.3312 |
E10.3313 |
E10.3319 |
E10.3391 |
E10.3392 |
E10.3393 |
E10.3399 |
E10.3411 |
E10.3412 |
E10.3413 |
E10.3419 |
E10.3511 |
E10.3512 |
E10.3513 |
E10.3519 |
E10.3521 |
E10.3522 |
E10.3523 |
E10.3529 |
E10.3531 |
E10.3532 |
E10.3533 |
E10.3539 |
E10.3551 |
E10.3552 |
E10.3553 |
E10.3559 |
E10.3591 |
E10.3592 |
E10.3593 |
E10.3599 |
E10.37X1 |
E10.37X2 |
E10.37X3 |
E10.37X9 |
E11.311 |
E11.319 |
E11.3211 |
E11.3212 |
E11.3213 |
E11.3219 |
E11.3291 |
E11.3292 |
E11.3293 |
E11.3299 |
E11.3311 |
E11.3312 |
E11.3313 |
E11.3319 |
E11.3391 |
E11.3392 |
E11.3393 |
E11.3399 |
E11.3411 |
E11.3412 |
E11.3413 |
E11.3419 |
E11.3491 |
E11.3492 |
E11.3493 |
E11.3499 |
E11.3511 |
E11.3512 |
E11.3513 |
E11.3519 |
E11.3521 |
E11.3522 |
E11.3523 |
E11.3529 |
E11.3531 |
E11.3532 |
E11.3533 |
E11.3539 |
E11.3551 |
E11.3552 |
E11.3553 |
E11.3559 |
E11.3591 |
E11.3592 |
E11.3593 |
E11.3599 |
E11.37X1 |
E11.37X2 |
E11.37X3 |
E11.37X9 |
E13.311 |
E13.319 |
E13.3211 |
E13.3212 |
E13.3213 |
E13.3219 |
E13.3291 |
E13.3292 |
E13.3293 |
E13.3299 |
E13.3311 |
E13.3312 |
E13.3313 |
E13.3319 |
E13.3391 |
E13.3392 |
E13.3393 |
E13.3399 |
E13.3411 |
E13.3412 |
E13.3413 |
E13.3419 |
E13.3491 |
E13.3492 |
E13.3493 |
E13.3499 |
E13.3511 |
E13.3512 |
E13.3513 |
E13.3519 |
E13.3521 |
E13.3522 |
E13.3523 |
E13.3529 |
E13.3531 |
E13.3532 |
E13.3533 |
E13.3539 |
E13.3551 |
E13.3552 |
E13.3553 |
E13.3559 |
E13.3591 |
E13.3592 |
E13.3593 |
E13.3599 |
E13.37X1 |
E13.37X2 |
E13.37X3 |
E13.37X9 |
H31.321 |
H31.322 |
H31.323 |
H31.329 |
H34.8110 |
H34.8120 |
H34.8130 |
H34.8190 |
H34.8310 |
H34.8320 |
H34.8330 |
H34.8390 |
H35.051 |
H35.052 |
H35.053 |
H35.059 |
H35.101 |
H35.102 |
H35.103 |
H35.109 |
H35.111 |
H35.112 |
H35.113 |
H35.119 |
H35.121 |
H35.122 |
H35.123 |
H35.129 |
H35.131 |
H35.132 |
H35.133 |
H35.139 |
H35.141 |
H35.142 |
H35.143 |
H35.149 |
H35.151 |
H35.152 |
H35.153 |
H35.159 |
H35.161 |
H35.162 |
H35.163 |
H35.169 |
H35.3210 |
H35.3211 |
H35.3212 |
H35.3213 |
H35.3220 |
H35.3221 |
H35.3222 |
H35.3223 |
H35.3230 |
H35.3231 |
H35.3232 |
H35.3233 |
H35.3290 |
H35.3291 |
H35.3292 |
H35.3293 |
H35.33 |
H35.711 |
H35.712 |
H35.713 |
H35.719 |
H40.50X0 |
H40.50X1 |
H40.50X2 |
H40.50X3 |
H40.50X4 |
H40.51X0 |
H40.51X1 |
H40.51X2 |
H40.51X3 |
H40.51X4 |
H40.52X0 |
H40.52X1 |
H40.52X2 |
H40.52X3 |
H40.52X4 |
H40.53X0 |
H40.53X1 |
H40.53X2 |
H40.53X3 |
H40.53X4 |
H40.89 |
H44.20 |
H44.21 |
H44.22 |
H44.23 |
H44.2A1 |
H44.2A2 |
H44.2A3 |
H44.2A9 |
H59.331 |
H59.332 |
H59.333 |
H59.339 |
H59.341 |
H59.342 |
H59.343 |
H59.349 |
S05.10XA |
S05.10XD |
S05.10XS |
S05.11XA |
S05.11XD |
S05.11XS |
S05.12XA |
S05.12XD |
S05.12XS |
S05.8X1A |
S05.8X1D |
S05.8X1S |
S05.8X2A |
S05.8X2D |
S05.8X2S |
S05.8X9A |
S05.8X9D |
S05.8X9S |
|
|
|
|
|
Covered Diagnosis Codes for Procedure Code Q5124
H35.3210 |
H35.3223 |
H35.3292 |
H35.3211 |
H35.3230 |
H35.3293 |
H35.3212 |
H35.3231 |
H35.3213 |
H35.3232 |
H35.3220 |
H35.3233 |
H35.3221 |
H35.3290 |
H35.3222 |
H35.3291 |
H34.8110 |
H34.8111 |
H34.8120 |
H34.8121 |
H34.8130 |
H34.8131 |
H34.8190 |
H34.8191 |
Covered Diagnosis Codes for Procedure Codes J2777
E08.37X1 |
E08.37X2 |
E08.37X3 |
E08.37X9 |
H35.3210 |
H35.3211 |
H35.3212 |
H35.3213 |
H35.3220 |
H35.3221 |
H35.3222 |
H35.3223 |
H35.3230 |
H35.3231 |
H35.3232 |
H35.3233 |
H35.3290 |
H35.3291 |
H35.3292 |
H35.3293 |
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475
, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.