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 What is a PPO? |
A PPO is a form of a managed care program that is closest to an indemnity plan. A PPO has
arrangements with doctors, hospitals, and other providers of care who have agreed to accept lower fees from the insurer for their services if you use their network of providers.
Unique Features of a PPO:
• Low co pays for most wellness/office visits when using a network provider.
• You can obtain services either from their network of providers or your personal provider (if not in the network). However, you will pay more if you do not use their network.
• No Primary Care Physician is required to coordinate your care.
• In-network coinsurance charges and out-of-network charges are reimbursed at Reasonable &
Customary (R&C) charges. Reasonable & Customary charges are those charges that fall within the range of fees normally charged for a given procedure by physicians with similar training and
experience in a geographic region.
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| What is the BlueCard PPO program? |
| BlueCard PPO is a network partnership with BlueCross and/or BlueShield plans across the country. Through this cooperative arrangement, you receive participating provider discounts and more efficient processing of medical claims. The BlueCard PPO program links each participating provider directly to BlueCross and/or BlueShield plans. This extensive network delivers your claim information electronically from health care providers to Blue plans all across the US. |
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| What is the advantage of using a BlueCard PPO provider? |
| If you use a BlueCard PPO provider, covered services will be paid at the higher in-network benefit rate. Additionally, the preferred provider will file claims for you. To locate a participating BlueCard PPO provider, visit www.bluecares.com or call (800) 810-BLUE. |
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| Do I have to use a BlueCard PPO provider? |
| No. You may go to any physician you choose. Although you save money when you visit a provider in the BlueCard network, you have the freedom to use any eligible licensed physician, specialist or hospital. |
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| How do I know if my provider is a BlueCard PPO provider? |
| Check the online directory (www.bluecares.com) and click on “National Doctor & Hospital Finder”.
Please remember that it is your responsibility to verify that the provider you are choosing to visit is a BlueCard PPO provider.
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What if I've already met my deductible this calendar year under my current medical plan? |
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| BCBS will give credit for prior deductibles met this calendar year. To receive deductible credit, fax a copy of your latest Explanation of Benefits (EOB) to the Health+ Service Center at 866-632-9373. |
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| What if I use a “non-preferred” provider? |
Covered services will be paid at the lower out-of-network rate, and you will pay more out-of-pocket.
You may also be asked:
• to pay for services up front
• to file your own claims with BlueCross BlueShield.
• you may be balance-billed if charges exceed the amount allowed by the local BlueCross and/or BlueShield plan Balance-billed means the provider will bill you for charges above the amount allowed by your plan or the difference between billed charges and the amount paid. Check your Benefits Summary or Certificate Booklet for out-of-network deductible and coinsurance levels of coverage allowed for the use of non-preferred providers.
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| Do I need a referral to go to a specialist? |
| No. You are free to visit any specialist whenever you like. If you choose a non-preferred specialist, your out-of-pocket costs will be higher than if you visit a preferred provider. Check your Benefit Summary or your Certificate Booklet for your out-of-network benefit level of coverage. If you need help selecting a specialist, the physician providing your primary care can probably make some helpful suggestions. However, please remember that it is your responsibility to make certain that the specialist is a preferred provider. It is not your doctor’s responsibility. |
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| What if I need to be hospitalized? |
| In most cases, you will work with your physician in advance on where you will go, what needs to be done and how long you will be in the hospital. Prior to your admission, you must pre-certify all
in-network or out-of-network admissions and outpatient surgical procedures. Emergency or maternity admissions must be certified within 48 hours of admission.
It is your responsibility to obtain pre-certification by calling (800) 722-6614.
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| What happens if my hospital admission is not pre-certified? |
| If you are admitted to a preferred or non-preferred hospital and receive treatment, you are liable for all denied charges if pre-certification is not obtained. |
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| Can I go to any hospital? |
| Yes. But, if you select a BlueCard PPO preferred hospital, covered services will be paid at the higher in-network rate, the hospital will file claims for you and you will not be balance-billed.
If you select a non-preferred hospital, covered services will be paid at the lower out-of-network rate and you will pay more out-of-pocket. Also, you may be asked to pay for some services up front, you may have to file your own claims and you may be balance-billed if charges exceed the amount allowed by the local BlueCross and/or BlueShield plan. Balance-billed means the provider will bill you for charges above the amount allowed by the local BlueCross and/or BlueShield plan or the difference between billed charges and the amount paid.
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| What is Blue Freedom Rx (the prescription drug program)? |
Blue Freedom Rx does exactly what its name suggests - it puts the freedom of choice in your hands.
• No formulary limitations
• No drug restrictions
• No prior authorization limitations
• Control over how much you spend out-of-pocket on prescription drugs
• More active role in your choice of drugs
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| How does it work? |
It’s simple. Blue Freedom Rx is a reference pricing pharmacy product that contains different “levels” of pharmacy benefits. These levels are determined by the average price of a drug within a specific category of drugs. The average price is referred to as the “reference price”. Each level has an associated payment level that you pay for your selected prescriptions. Blue Freedom Rx consists of four copayment/coinsurance levels:
Level 1: Generic drugs that cost less than the reference price.
Level 2: Brand drugs that cost less than the reference price.
Level 3: Generic or brand drugs that cost more than the reference price.
Level 4: Self-injectibles (some exclusions apply; for example insulin).
*For the copayment/coinsurance levels specific to your benefit plan, please refer
to your Benefit Summary.
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| How do I know the level of my prescription drug? |
| The BlueCross BlueShield of Georgia web site (www.bcbsga.com) has a list of hundreds of the most commonly prescribed prescription drugs that are currently in use today. Next to each drug is an indicator letting you know which level of payment will be required. To make it even easier, we’ve listed these drugs alphabetically by drug category (i.e., asthma, arthritis, stomach/ulcer, etc.). |
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| What if my drug is not listed on the web site? |
| If your drug is not included on the list, simply call customer service at (800) 441-CARE (2273).
A customer care associate stands ready to answer your questions from 7 AM to 7 PM, Monday through Friday (excluding holidays).
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| Where can I get my prescriptions filled? |
| BlueCross BlueShield extensive pharmacy network includes certain local independent pharmacies as well as many national chain pharmacies (Bi-Lo, CVS, Eckerd, Kroger, Publix, Walgreens, Wal-Mart, Winn-Dixie). A complete listing of network pharmacies is included in the “Pharmacies” section of your Member Guide/Provider Directory. You can also access the online Provider Directory at www.bcbsga.com. |
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| Is there a preferred list of dentists? |
| Yes, but you may see any dentist you choose. Please keep in mind, however, that BlueCross BlueShield pays 100%, 80%, or 50% of usual, customary, and reasonable charges, so, if you use a non-network provider, you may be balance-billed if your provider charges above this level. If you use a BCBS network provider, you will not be balance-billed. |
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| Can I find out what will be covered prior to treatment? |
Yes. BlueCross BlueShield strongly recommends that you have your dentist submit a pre-treatment estimate (or predetermination) for services in excess of $200. This often applies to services such as crowns, bridges, inlays, endodontics, and periodontics. Once your dentist files a pre-treatment estimate with BCBS, BCBS will provide an estimate of which services they will cover and at what payment level.
Send dental claims to:
Wellpoint Dental Services/BlueCross
P. O. Box 9201
Oxnard, CA 93031
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| Do I need an identification card? |
| No. Spectera makes it easy to access your benefits. We offer a paperless system, so there are no identification cards to track. When making your appointment, simply give the Spectera provider the subscriber’s unique identification number, along with the patient’s name and date of birth, and identify the patient as a Spectera member. The provider will verify the patient’s eligibility and coverage with us prior to the scheduled appointment. |
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| What is my unique subscriber identification number? |
| The enrolled employee’s Social Security number. |
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| How often should I have my eyes examined? |
| You and your eye care provider should determine the eye exam schedule that best meets your eye care needs. The American Optometric Association recommends that adults age 19 to 40 with normal vision receive eye exams every two to three years, adults 41 to 60 receive eye exams every two years, and adults 61 and older receive annual eye exams. People with vision problems, including those who wear prescriptions, should visit their eye care professional at least annually. |
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| What is the difference between a routine eye exam and a contact lens exam? |
Routine eye exams are designed to detect vision problems and are an important preventive measure for maintaining your overall health and wellness. In fact, eye exams can be used to spot symptoms of diseases and conditions like diabetes, high cholesterol, hypertension, cataracts, multiple sclerosis, brain tumors, lupus, AIDS, osteoporosis, rheumatoid arthritis, and Graves' disease.
Contact lens exams are designed to evaluate your vision with contact lenses. Your eye care provider will check to ensure the contacts fit properly. |
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| Why should I have a regular eye exam? |
| Regular eye examinations are important to your overall health. In fact, eye exams can be used to spot symptoms of diseases and conditions like diabetes, high cholesterol, hypertension, cataracts, multiple sclerosis, brain tumors, lupus, AIDS, osteoporosis, rheumatoid arthritis, and Grave's disease. |
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| Am I limited in the kind of frames I can choose? |
| If you visit a participating Spectera provider and select a frame with a price equal to or less than your plan allowance, there is no cost to you, other than applicable copays. If you select a frame that exceeds your plan allowance, your allowance will be applied to the price of the frame and you are simply responsible for the difference. |
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| How do I identify myself as a Spectera member with a vision care provider? |
| When contacting the provider to make your appointment, simply give the Spectera network provider the subscriber’s unique identification number, the patient’s name and date of birth, and identify the patient as a Spectera member. The network provider will verify the patient’s eligibility and coverage with us prior to the scheduled appointment. |
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| How do I submit a claim? |
If you visit a network provider, there are no claim forms to fill out or file. When making an appointment, identify yourself as a Spectera member.
If you visit a provider outside Spectera’s network, you pay the provider in full at the time of service. Then simply mail or fax your receipts to Spectera, requesting reimbursement. They will process your claim and reimburse you up to the maximum allowances of your out-of-network schedule.
To request reimbursement, submit your receipts to:
Spectera Claims Department
PO Box 30978
Salt Lake City, UT 84130
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Fax: 248-733-6060
The following information should be included with your itemized receipt submission:
• Subscriber’s name and address
• Member or patient's name and date of birth
• Subscriber's unique identification number
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| Can I get contact lenses instead of glasses? |
| Yes. Your plan will cover contact lenses in lieu of eyeglasses (once every 12 months). |
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| Is laser vision correction a covered benefit? |
In response to the ever-increasing popularity of laser vision correction, Spectera has partnered with the Laser Vision Network of America to provide members with access to discounted laser eye surgery procedures. Spectera members may receive discounts of 15 percent off the standard or usual and customary price, or five percent off any promotional price.
The Laser Vision Network of America, 1-877-28-SIGHT, provides Spectera members with a nationwide network of more than 400 laser vision locations, all of whom are credentialed according to NCQA-recommended standards. This money-saving offer is exclusively for Spectera’s vision care members. |
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| How do I obtain a list of vision care providers in Spectera’s network? |
Simply select our provider locator and enter the subscriber's unique identification number and ZIP code. A list of providers, along with their address, phone number, and door-to-door directions (including mileage) will be displayed.
In addition, Spectera provides a 24-hour automated Interactive Voice Response (IVR) system. A toll-free call is all that is necessary to choose from a continuously updated directory of providers. Call 1-800-638-3120, select the provider locator option, and key in the subscriber's unique identification number and the desired ZIP code. A list of providers, along with their address and phone number will be given.
If you prefer to speak to a customer service representative, they are available Monday through Friday, 8:00 a.m. to 11:00 p.m., and Saturday, 9:00 a.m. to 5:30 p.m., Eastern Standard Time at 1-800-638-3120. |
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