Blue Cross PPO - Questions & Answers

I like my current doctor. Can I continue to see him or her under either of these plans?

Under the BlueCard PPO plan, you may visit the provider of your choice. However, if he or she does not belong to the BlueCard PPO network, out-of-network rates will apply, meaning that you will pay a deductible and a higher percentage of the cost. Many health care providers belong to more than one network-check the BlueCard PPO provider directory to learn if your doctor is a network provider. Exceptions to the plan policy may be made in cases of ongoing treatment for serious illness or OB-GYN care during the second or third trimester of pregnancy. Under these circumstances it is especially important to have a smooth transition of care from one health care plan to another. Transition of Care (TOC) provisions apply under special circumstances such as those listed above to allow you to continue treatment with out-of-network providers at network rates for a limited period of time following the effective date of the health plan or termination of your current health plan. To request transition of care initiated prior to becoming a BlueCard member, contact BlueCard customer service at 1-866-870-0413 (in The Twin Cities, call 651-662-5505).

Where can I find a list of providers for my plan?

Simply call 1-800-810-BLUE (2583) to locate a BlueCard PPO provider. You can also visit http://www.bcbs.com/healthtravel/finder.html to search by location, specialty, or provider name. You will be given the choice to search for a BlueCard PPO provider or a BlueCard traditional provider. If you have the PPO plan, be sure to search for a BlueCard PPO provider.

Am I covered by my plan when I travel internationally?

The BlueCard PPO plan has arrangements with providers throughout the world. Out-of-network rates will apply when you travel outside of the United States, but by using a network provider you'll pay only out-of-pocket costs as the provider will directly bill the plan for covered services. Always carry your BlueCard ID card with you when you travel, and call the number listed on the card for prior authorization. Before an extended trip, visit to http://www.bcbs.com/healthtravel/finder.html or call 1-800-810-BLUE (2583) for help locating network providers in the area you will be visiting. Note: Special benefits apply in emergency situations. Contact BlueCard customer service at 1-866-870-0413 (in the Twin Cities, call 651-662-5505) for more information.

If I choose to visit a provider outside my plan's network, how do I file a claim?

Call BlueCard customer service at 1-866-870-0413 (in the Twin Cities, 651-662-5505) to request a claim form. Provide the requested documentation of the service and submit the form as instructed. You'll be reimbursed for covered services less any applicable deductibles and coinsurance.

What does "usual and customary" mean?

"Usual and customary" is a guideline that insurance companies use to determine how much of a medical expense the plan will consider for coverage. A "usual" fee is the charge made for a given service by a doctor to the majority of his or her patients. A "customary" fee is one that is charged by the majority of doctors within a community for the same services. Generally, only charges for expenses up to the usual and customary level are eligible for consideration for coverage by a medical plan. Usual and customary considerations usually do not apply to services from network providers, because these providers charge fees according to negotiated rate agreements. However, usual and customary considerations are generally applied to out-of-network services if covered by your plan.

Do I need to select a primary care physician with my plan?

Do I need a referral to see a specialist? No, you do not need to select a primary care physician, although it's a good idea to build a relationship with a provider who understands your health history and can help coordinate your care. You may see any network specialist you choose without a referral. Out-of-network rates will apply if the specialist is not a BlueCard network provider-even if a BlueCard network doctor referred you.

What is a deductible?

A deductible is the amount of expenses for eligible services that you must pay out of pocket before the plan begins to pay benefits. There is no deductible under the BlueCard PPO plan for care from network providers. Out-of-network benefits will begin after a $500/person and $1000/family annual deductible for BlueCard PPO.

What is an out-of-pocket maximum?

"Out-of-pocket" refers to the expenses you pay for services, including coinsurance and deductibles (but not insurance premiums). Plan maximums are the most you'll pay in "out-of-pocket" costs in a single plan year. If you face very high medical expenses during the plan year, thanks to the out-of-pocket maximum, your share of the costs will not exceed $1,000 for care per person from network providers or $3,000 for care per person from out-of-network providers. Out-of-pocket maximums per family are $2,000 for in-network providers and $6,000 for out-of-network providers, regardless of the number of dependents covered.

Will I receive a medical ID card?

You will receive a BlueCard ID card 2 to 3 weeks after the enrollment period ends. The ID card lists important information such as your plan number and must be presented to the physician or hospital when you require medical care. Call BlueCard customer service at 1-866-870-0413 (in the Twin Cities, 651-662-5505) if you need a replacement card.

What coverage is available through my plan for prescription drugs?

When you use a network pharmacy, covered prescription drugs are available after co-payments. Your co-pay per prescription will be $15 for generic drugs, $25 for brand name drugs that are on the formulary and $35 for brand name drugs that are not on the formulary. Your physician or pharmacist should have a copy of the formulary. You can also utilize the Mail Order program and receive a three-month supply for the price of a two-month supply.

Does my medical plan provide any dental coverage?

The BlueCard PPO plan covers accidental injury to sound and natural teeth, hospitalization necessary for dental services, and non-dental, but medically necessary, oral surgery procedures. Preventive coverage and additional dental coverage is available through the eFunds dental plan.

Can I change my medical coverage during the plan year?

You may only change your medical coverage during the plan year if you experience a change in family status. If you experience a change in family status and wish to change your medical coverage, you must complete the Family Status Change form located under the Forms link in eServe. You must make any changes to your medical coverage resulting from your change in family status within 31 days of the event. Changes in family status include:

• Marriage·
• Divorce or legal separatio·
• Birth or adoption of a child
• Dependent child's loss of eligible dependent status under the plan
• Death of your spouse or a dependent
• Change of employment status for you or your spouse
• Change in place of residence or worksite
• Qualified Medical Child Support Order (QMCSO)
• Entitlement to Medicare or medical benefits

Proof of these events is required and should be attached to the Family Status Change Form. Examples of proof are:

• a copy of a birth certificate or adoption placement paperwork for a new dependent child
• a copy of a marriage license for a marriage
• a copy of the divorce decree for a divorce, etc.

If you have questions about proper supporting documentation, please email Benefits@eFunds.com.These changes must be consistent with the event. Example: If you are covered under a spouse's insurance plan, and you are enrolled in the medical and dental options, and that coverage is lost, you can only elect medical and dental coverage under the eFunds plan. If you experience a change in family status and wish to change your benefits, you must complete the Family Status Change form located under the Forms link in eServe. You must make any benefit changes resulting from a change in family status within 31 days of the event.

Can I waive medical coverage?

You may waive medical coverage. You will receive the eFunds waiver reimbursement only if you provide confirmation of existing coverage elsewhere, e.g., through a spouse's medical plan. Confirmation of existing coverage must be sent to the Benefits Department on letterhead from the employer or a copy of the current ID card from the company providing coverage. If you waive coverage, you will not be eligible for eFunds coverage until the next annual enrollment unless you experience a change in family status, as defined in the previous question. If you experience a change in family status and wish to change your benefits, you must complete the Family Status Change form located under the Forms link in eServe. You must make any benefit changes resulting from a change in family status within 31 days from the date of the event.

Who do I call if I have questions about my medical coverage?

You can find answers to your questions about your BlueCard PPO medical coverage by calling BlueCard customer service at 1-800-711-9867 (in the Twin Cities, call 651-662-5227). Representatives are available to answer your questions on Monday through Thursday from 8 a.m. to 7 p.m. CST, and from 9 a.m. to 4:30 p.m. CST on Fridays.