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2010 Benefits OverviewPPO Plan 3562

Overview of Health Products PPO Plan 3562

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Health Plan Terminology• Deductible – what member pays before health plan pays

• Copayments (copays) – a set amount member pays for covered services

• Coinsurance – how a member and the company share costs after deductibles and copays: e.g., 80%/20% or 70%/30%

• Annual out-of-pocket (OOP) maximum (max) – the maximum a member pays out-of-pocket in any benefit year– BlueOptions® – max includes all applicable health-related copays

(except Rx), deductibles, and coinsurance

• Allowed amount – maximum amount an in-network provider is allowed to charge for covered service

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Other Words to Know• Balance billing – additional amount member may be billed if they seek

care from an out-of-network provider• Covered services – medical services that are eligible for payment under

health plan• In-network – refers to provider network made up of independent

hospitals, physicians and ancillary providers (e.g., family physician, urgent care centers, hospitals) who are participants within health plan network; members pay less if they receive covered services from in-network providers. The in-network name is: NetworkBlueSM (BlueOptions®)

• Out-of-network – provider not in network; out-of-pocket costs will generally be higher

• Provider – person or institution offering health care services (e.g., doctors, specialists, hospitals, labs)

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Office VisitsFamily Physician/PCP

Specialist

$20

$35

Any services received at doctors office will apply to copay.

Lab

In Network – Quest

Out of Network

$0

CYD + 30%

Lab is paid at 100% by using Quest. You can make appointments online!!!

www.questdiagnostics.com

Out-of-Network CYD + 30% Anything other than NetworkBlue is Out of Network. Using Traditional doctors will protect you from balance billing.

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Preventative Health

MammogramIn addition to the $500 Adult Wellness Benefit

$0 Based on doctor’s recommendation.

Adult WellnessAny allowances in excess of $500 will be the responsibility of the member

$500 See 2009 Clinical Preventive Care Guidelines on next slide.

ColonoscopyAdult Wellness Benefit

One routine colonoscopy (age 50+ paid in full of allowed amount)

Included in the $500 Adult Wellness Benefit

The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) using a colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.  

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2009 Clinical Preventive Care Guidelines – Child Preventive Schedule

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2009 Clinical Preventive Care Guidelines – Child Immunizations

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2009 Clinical Preventive Care Guidelines – Adult Preventive Schedule

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2009 Clinical Preventive Care Guidelines – Adult Preventive Schedule

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Hospital Services - InpatientInpatient Facility Copay

In-Network

Out of Network

$750/$1,500

$2,500

To determine tier levels or participation, go to the Online Provider Directory www.bcbsfl.com

Provider Services while Inpatient

In Network

Out of NetworkCYD + 20%

CYD + 30%

Any services received by a Provider while in the hospital.

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Hospital Services - Outpatient

Outpatient

In-Network Hospital

Out of Network

$150/$250

$350

To determine tier levels or participation, go to the Online Provider Directory www.bcbsfl.com

Provider Services while Outpatient

In Network

Out of NetworkCYD + 20%

CYD + 30%

Any services received by a Provider

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Deductible & Coinsurance

Calendar Year Deductible

Coinsurance

In Network

Out of Network

$500/$1,500

20%

30%

Applies to services such as Provider Services in Hospital, Independent Diagnostic Testing Facility, Durable Medical Equipment, Prosthetics & Orthotics and Ambulance Services

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Out of Pocket Maximum

In Network and Out of Network (Combined)

Per Person/Family $ 5,000/$10,000

The maximum a members pays out of pocket in a benefit year. All of the following is applied to Max Out of Pocket: Copays except RX, Calendar Year Deductible and Coinsurance

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Pharmacy

Mandatory Generic30 Day Supply

Mail Order90 Day Supply

$15/$40/$60

$30/$80/$120

If a Brand Name RX is purchased when a Generic RX is available and the Physician has not indicated that a Brand Name RX is medically necessary, member will be required to pay the difference between the cost of the Brand Name and Generic RX in addition to the RX copay

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Diabetic Supplies - Medical

• Covered Under Medical When Physician That Specializes in the Treatment of Diabetes Certifies Services are Medically Necessary– Self Management Training and Educational Services– Nutritional Counseling provided by a Licensed Dietitian– Trimming of toenails, corns, calluses– Therapeutic Shoes including Inserts and/or Modifications

for the treatment of severe Diabetic Foot Disease– Insulin Pump/Supplies (Durable Medical Equipment)

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Diabetic Supplies - Pharmacy

• Insulin• Syringes and needles for injecting Insulin• Blood Glucose Testing Strips and Tablets• Lancets• Glucose Monitor• Acetone Test Tablets

Want to get the most out of your next doctor's visit?

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The more you tell your doctor about your health concerns, the better he or she can prevent, diagnose, or treat any problems. Follow these tips to get the most from each doctor visit.

Preparing for your doctor's visit A little preparation can go a long way, saving you time and money.

•Be sure to check our online provider directory to see if your doctor participates in our network. Your cost will be lowest when you use a participating health care provider.•Write down your concerns and questions before your visit, and bring them with you.•Bring paper and pen to take notes.•Ask a family member or friend to come along. They can help you ask questions and understand the answers.

What Your Doctor Needs to Know Be sure you cover these topics:

•Any health concerns you have–even sensitive subjects•Your symptoms, including when they began, how often they occur, how long they last, and whether they're getting worse•Services or tests other doctors have performed for you•All medications and supplements you take; bring a list or the actual products•Your family's medical history •Let your doctor know before your visit what language you prefer to speak or if you need an interpreter.

What You Need to Know Before you leave the doctor's office, you may want to ask these questions:

•What is my condition, and what caused it?•Which medications or other treatments do you recommend? How will they help?•Will there be any side effects?•Can lifestyle measures help my condition?•Should I avoid certain medicines, activities, or foods?•What kind of tests do I need–and why? •How soon will test results be available, and how will I get them?If you don't understand an answer or feel concerned about it, speak up!

When you need to see a doctor right away…For non-emergency assistance—when you can’t get in to see your family doctor or don’t want to wait hours in the emergency room—urgent care centers are designed to provide prompt, quality service and help you save up to 50% on your out-of-pocket costs.•Urgent care centers are staffed with qualified doctors and nurses that can handle medical problems like cuts and colds, flu symptoms, minor fractures, sprains and burns, ear infections, allergic reactions, animal bites, sprains and even immunizations.•Most urgent care centers offer: Quality care and prompt service•Shorter wait times—compared to an emergency room•Weekend and after-hours care•Service without an appointment•Convenient locations•Check our online provider directory to find participating urgent care centers located near you. Keep the names and addresses in a convenient place should you need them in a hurry.•Serious injuries and emergencies•If you have a serious injury or require immediate attention due to shortness of breath, severe abdominal or chest pains, uncontrolled bleeding, loss of consciousness, changes in vision, severe vomiting or other emergency conditions, call 911 or visit the nearest hospital.•Be sure to contact your family doctor so that follow-up care can be scheduled, if necessary.•Help is a phone call away•If you have questions about a health condition or when to visit an urgent care center, you can speak to a Health coach by calling 1-877-789-2583. 19

Know about generics and how to get them…

One of the easiest ways to save money is to use the generic version of a prescribed brand-name drug when one is available. Your cost will be lower without sacrificing quality. So if you are starting a new medicine or re-filling one, you may want to talk to your doctor, or have your pharmacist talk with your doctor, about whether a generic is available and right for you.•Check out this comparison chart and find generics using our online pharmacy tool.•Over-the-Counter options can lower your costs•Looking for ways to save money on medicine? There are other ways of filling the medicine cabinet without depleting your pocketbook. The key? Look for nonprescription, over-the-counter (OTC) medication.•Check with your doctor. An OTC may work for you.•OTC medication is medicine that can be sold without a prescription and is found on the shelves of stores like other packaged products. Many OTC medications are just as effective as prescription drugs. In fact, many OTC drugs were once available only with a prescription. These include popular pain relievers and allergy medications as well as drugs that fight ulcers, help you quit smoking, and more. Your doctor can tell you if an OTC medication can replace one of your prescriptions.

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How to save on your next scan

How to save on your next scan• Not all imaging providers charge the same for their services. For example, an independent imaging center

may charge less than a hospital. To help you reduce your out-of-pocket costs, it pays to do a little legwork.• Here are some ways to make the most of your benefits and lower your costs:• Discuss your imaging options with your doctor. Are there other ways to diagnose your condition that are

just as effective?• If your doctor recommends a CAT scan, PET scan, MRI, MRA or nuclear cardiology, ask where it will be

performed. You’ll have lower out-of-pocket costs if you use providers and facilities that participate in your plan’s network.

• To save even more money, ask your doctor if your test can be done at an in-network Independent Diagnostic Testing Facility (IDTF). Services at an IDTF generally cost less than the same services done in an outpatient hospital setting.

• Use our online provider directory or call the number on your ID card to verify whether or not the providers and facilities participate in your plan’s network.

• Ask your doctor to request a pre-service review for these procedures. That way, you’ll always know up front whether the service is a covered benefit. Please be aware that you may be responsible for the cost of procedures you receive that are not considered medically necessary.

• Go to http://www.bcbsfl.com/HealthySavings/surgery/doctorSaysSurgery.html for additional information on healthy savings.

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FAQ’s• Where can I go to get information about a claim?

– Visit www.bcbsfl.com and go to Claims under the My Benefits menu section to view and print details of your claims.• When I receive services outside the State of Florida, who submits the claim to BCBSF?

– Under the BlueCard Program, if the physician or provider is participating in the Blue Cross and Blue Shield network in that state, they will reimburse the physician or provider for the services you receive and them submit claim to BCBSF for reimbursement. If you should receive a bill from the physician or provider, please contact Customer Service at 800-255-4908 for assistance.

• What makes up Member Responsibility? – Member Responsibility is the out-of-pocket portion of a claim that a member is expected to pay. For example, deductibles,

copayments, and non-covered services are Member Responsibility. • What if I have a question about a claim?

– When you log onto MyBlueService, you can email us a question concerning your claim by selecting Ask a Question about this Claim at the bottom of the Claim Status Detail page. You will receive a reply in the Message Center or you may call us at 800-255-4908.

• Do I have to submit claims? – Not if you choose a provider from within your plan provider network. Your provider should process all claim submission paperwork on

your behalf. If you choose a provider outside the network, you may have to file claims for reimbursement. • Where can I find my Member Health statement?

– Select Claims Statements under the My Benefits menu in MyBlueService.• Where can I find my Explanation of Benefits statements?

– These are located on your Claims Details pages. Select Claims under the My Benefits menu and locate the specific claim you are looking for.

• What is an Explanation of Benefits statement? – An Explanation of Benefits (EOB) is a detailed statement that explains how we processed a medical claim based on your benefits plan.

It shows how much was paid by your insurance plan, any out-of-pocket expenses that are your responsibility, and accumulation of deductibles. Depending on your plan, you may or may not receive Explanation of Benefits statements.

• What is a Member Health statement? – A Member Health Statement is a detailed reference of finalized health and pharmacy claims activities for the preceding 28-days. This

statement allows members to track claims and reconcile provider balances and can be used as documentation for FSA, HRA and HSA accounts.

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Things To Remember

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Save Money

• Use NetworkBlue doctors• Use Quest Laboratories • Stay in network using Online Provider Directory• Provide doctor and pharmacy your ID card• Log on to MyBlueService to view claims, benefit

information, order new ID Cards and Member Handbooks

• Call Customer Service when you have questions1-800-255-4908