Preferred Provider Organization (PPO/PPN)

Note: The information below briefly describes important features about this health care program. It is not a contract. A detailed description of the benefits is included in the Evidence of Coverage. Please refer to the Evidence of Coverage for specific terms, conditions, limitations and exclusions.

The Preferred Provider Organization (PPO/PPN) is a plan that gives employees the flexibility they want with the medical coverage and service they need.Members pay only a small copayment or coinsurance each time they see a physician.

When they choose to have medical care provided by a physician or hospital within PPO/PPN, they will receive the highest level of benefits for their care.

If they choose to have medical care provided by a physician or hospital outside of PPO/PPN, out-of-network benefits are available for covered services, although they will incur higher out-of-pocket expenses.

Advantages:

  • Members do not need to choose a Primary Care Physician (PCP) and they will never need a referral.
  • Freedom to choose any doctor, specialist or hospital - anytime members wish.
  • No paperwork or claims to file when members use participating providers and hospitals.
  • No balance billing** when members use participating providers and hospitals.
  • Coverage when your employees travel. The BlueCard Program allows members to receive in-network benefits while they live or travel outside our service area.

Preventive Care:

  • Well-child care, including immunizations
  • Routine gynecological care
  • Routine adult physicals
  • Chlamydia screening
  • Prostate cancer screening
  • Mammography screening
  • Hearing screening for newborns
  • Osteoporosis prevention and treatment
  • Colorectal cancer screening

Medical Benefits:

  • Surgery
  • Hospitalization/inpatient services up to 365 days
  • Outpatient hospital services
  • Emergency care for injury and illness
  • Office visits for illness
  • Maternity care and infertility services
  • Diagnostic tests and X-rays
  • Allergy testing and injections
  • Home health care
  • Hospice care
  • Durable medical equipment
  • Medical supplies

3-Tier Prescription Drug Plan:

  • Tier 1 - Generic copays offer the lowest cost to the member $
  • Tier 2 - Copays for formulary/preferred brand name drugs are higher than for generic drugs $$
  • Tier 3 - Copays for nonformulary/nonpreferred brand name drugs have the highest level of copay $$$

Additional Features:

  • No-cost preventive services for children and adults
  • Disease management programs for members with chronic asthma, diabetes, congestive heart failure, coronary heart disease or chronic obstructive pulmonary disease (COPD)
  • Vitality member magazine
  • Great Beginnings program for expectant mothers
  • Health education programs
  • Discounts on alternative therapies: Options provides discounts on alternative therapies including acupuncture, massage therapy, and chiropractic care. It also provides discounts for fitness center memberships and weight loss programs.
  • 24/7 Advice: FirstHelp gives 24-hours a day, 7-days a week health care advice from registered nurses who can answer your employees' health care questions and help guide them to the most appropriate care.

Dental and Vision Coverage May Be Purchased Separately:

Dental Plans:

  • Traditional Dental
  • Preferred (PPO) Dental

Vision Plan:

  • BlueVision Plus

Frequently Asked Questions:

  • Get answers to Frequently Asked Questions regarding this plan.

** Plans typically have some member out-of-pocket costs in the form of copayments, coinsurance, deductibles or annual maximums. Please refer to the Evidence of Coverage for more information.

For more information about this plan, contact our Member Services Department at the phone number on your member ID card.