Transcription of Blue Shield PPO Plan Frequently Asked Questions
1 1 Blue Shield PPO plan Frequently Asked Questions If you have any Questions about your plan benefits, call your dedicated Blue Shield Member Services team at (855) 724-7698. They are available to assist you from 7 to 7 Pacific time, Monday through Friday. You can also go to for basic information about the PPO plan . GENERAL 1. What is the PPO plan ? With the PPO plan , you can receive care from any of the physicians and hospitals within the plan s network, as well as outside of the network for covered services. Within the provider network Preventive care services such as a flu shot are fully covered.
2 You pay 100% for all other services until you meet your plan -year deductible. After your deductible is met, you pay a copayment or coinsurance for covered services. PPO network providers submit their claims directly to Blue Shield , so it s convenient for you. Outside the provider network When you see a non-network provider, what you ultimately pay depends on fees above Blue Shield s allowable amounts. Those fees vary and can be costly. For covered services: You pay 100% of the amount billed until you meet your plan -year deductible.
3 Only the amount allowed by Blue Shield applies to your deductible. After you meet your deductible, you pay a copayment or coinsurance based on Blue Shield s allowable amount, plus any charges above the allowable amount. Non-network providers usually require you to pay the full amount at the time you receive care. You then submit a claim with an itemized doctor s bill to Blue Shield . 2. Does the PPO plan offer any wellness programs? With the PPO plan , you can participate in Wellvolution , Blue Shield s easy, social and fun approach to wellness.
4 Wellvolution features easy-to-use online programs that can help you learn about your health and improve your well-being. You can also invite your family and friends to join. Visit for access to: 2 Well-Being Assessment Complete a short questionnaire and receive a confidential, personalized report of your overall well-being, including ways you can improve your health. Daily Challenge With Daily Challenge , you will receive a daily email that includes suggestions for simple and fun wellness-related tasks that can help improve your well-being.
5 QuitNet Get the help you need to quit smoking with encouragement and support from the largest quit-smoking community in the world. QuitNet now includes nicotine replacement therapy (NRT) at no additional cost. Walkadoo Walkadoo is a wellness program for every walk of life. Make a move toward better health by using your smartphone to receive your daily step goals and count your steps or bring your own step tracker. Note: The Walkadoo app is available for iPhone 5s and later, and Android version 14 (Ice Cream Sandwich) and later.
6 Walkadoo is also compatible with all models of Fitbit, Jawbone and Misfit, as well as the Moves app for iPhone and Android . Diabetes Prevention Program You may be eligible for the Diabetes Prevention Program. This program can help you lose weight, adopt healthier habits and reduce your risk of developing type-2 diabetes. It s available at no cost to members who qualify. Find out more at MEDICAL BENEFITS 1. How do I know if my doctor is in the PPO network? To search for a network provider, go to 2. What if my current doctor is not in the PPO network?
7 When you see a non-network provider, what you ultimately pay depends on fees above Blue Shield s allowable amounts. Those fees vary and can be costly. For covered services: You pay 100% of the amount billed until you meet your plan -year deductible. Only the amount allowed by Blue Shield applies to your deductible. After you meet your deductible, you pay a copayment or coinsurance based on Blue Shield s allowable amount, plus any charges above the allowable amount. Non-network providers usually require you to pay the full amount at the time you receive care.
8 You then submit a claim with an itemized doctor s bill to Blue Shield . 3 3. Do I need to select a primary care physician? With a PPO plan , there is no requirement to select a primary care physician (PCP). You can choose any doctor or specialist in your plan s network and make an appointment. While the PPO plan doesn t require you to select a PCP, building a relationship with a primary care physician that provides primary care has several advantages. A primary care physician: Gets to know you well and understands your healthcare needs, and Can help you achieve your health and well-being goals 4.
9 What is the difference between a primary care physician that provides primary care and a specialist? Primary care physicians are usually general practitioners, including internal medicine and family practice doctors as well as pediatricians. Specialists focus on one area of medicine, such as dermatology, OB/GYN, or allergies. 5. Is there a medical office or group where I can select all the doctors for my family in one place, so I don't have to go to multiple locations? In other words, can I avoid going to one office for primary care, another office for OB/GYN, and yet another for pediatricians?
10 Unlike an HMO, a PPO plan does not require you to choose doctors who belong to only one medical group. We are contracted with individual physicians as well as multi-specialty medical groups so you can get many of your healthcare needs in a single location. You can use our online Find a Doctor tool at to look up the locations of any doctors. 6. If I need to see a specialist, do I need a referral from a provider I ve visited for primary care (such as my primary care physician) or can I select one myself and make my own appointment?
