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Medical Care Benefits – Preferred Provider Organization (PPO)

Call toll-free:  Blue Cross Blue Shield of Minnesota: 800-793-6922

Members receive greater benefits if they access care through a physician in the network and use network providers for health services. The member does not have to select a primary care physician and can self-refer to any specialist physician in the network. If non-network providers are used, benefits are still payable but at a lower percentage and after a deductible is satisfied.

 
Option A
To see a complete summary of benefits for this option, click here.


Network Benefit Member Pays...

Non-Network Benefit Member Pays...

Individual Deductible

$0

$500

Family Deductible

$0

$1,000

Coinsurance

10%

30%

Individual Coinsurance Maximum

$600

$2,100

Family Coinsurance Maximum

$1,200

$4,200

Preventive Care

$0

100%

Office visits (other than preventive care)

$25 copay

$50 copay

Well baby and child care (under age 6)

$0

100%

Inpatient and Outpatient Hospitalization & Other Medical Expenses 

10%

30% after deductible

Emergency Room

$120 copay (waived if admitted) 

$120 copay (waived if admitted)

Urgent Care


$25 copay

$50 copay

Lifetime Maximum

Unlimited lifetime maximum and includes all CHP-eligible benefits.

 

Option B
To see a complete summary of benefits for this option, click here.


Network Benefit Member Pays...

Non-Network Benefit Member Pays...

Individual Deductible

$350

$700

Family Deductible

$700

$1,400

Coinsurance

15%

40%

Individual Coinsurance Maximum

$1,750

$4,650

Family Coinsurance Maximum

$3,500

$9,300

Preventive care

$0

100%

Office visits (other than preventive care)

$25 copay

$50 copay

Well baby and child care (under age 6)

$0

100%

Inpatient and Outpatient Hospitalization & Other Medical Expenses 

15% after deductible

40% after deductible

Emergency Room

$120 copay (waived if admitted) 

$120 copay (waived if admitted)

Urgent Care


$25 copay

$50 copay

Lifetime Maximum

Unlimited lifetime maximum and includes all CHP-eligible benefits.

 

Option C
To see a complete summary of benefits for this option, click here.


Network Benefit Member Pays...

Non-Network Benefit Member Pays...

Individual Deductible

$600

$1,200

Family Deductible

$1,200

$2,400

Coinsurance

20%

40%

Individual Coinsurance Maximum

$2,400

$6,000

Family Coinsurance Maximum

$4,800

$12,000

Preventive Care

$0

100%

Office visits (other than preventive care)

$30 copay

$60 copay

Well baby and child care (under age 6)

$0

100%

Inpatient and Outpatient Hospitalization & Other Medical Expenses 

20% after deductible

40% after deductible

Emergency Room

$120 copay (waived if admitted) 

$120 copay (waived if admitted)

Urgent Care

$30 copay

$60 copay

Lifetime Maximum

Unlimited lifetime maximum and includes all CHP-eligible benefits.

 

Option D
To see a complete summary of benefits for this option, click here.


Network Benefit Member Pays...

Non-Network Benefit Member Pays...

Individual Deductible

$1,200

$2,400

Family Deductible

$2,400

$4,800

Coinsurance

20%

40%

Individual Coinsurance Maximum

$3,000

$9,000

Family Coinsurance Maximum

$6,000

$18,000

Preventive Care

$0

100%

Office visits (other than preventive care)

$35 copay

$70 copay

Well baby and child care (under age 6)

$0

100%

Inpatient and Outpatient Hospitalization & Other Medical Expenses 

20% after deductible

40% after deductible

Emergency Room

$120 copay (waived if admitted) 

$120 copay (waived if admitted)

Urgent Care

$35 copay

$70 copay

Lifetime Maximum

Unlimited lifetime maximum and includes all CHP-eligible benefits.


Prescription Drug Expenses

Administered by Express Scripts: 800-789-7488

Click here to view the 2014 Express Scripts Preferred Drug List
Click here to view the 2014 Preferred Drug List Exclusions
Click here to view the 2014 Specialty Drug List
Click here to view a listing of Drugs/Supplies Not Covered by CHP
Click here to view a listing of Drugs requiring prior authorization
Click here to view the 2014 Quantity Limit List of Drugs
Click here for Step Therapy Information
Click here for Step Therapy Programs and First-line/Second-line Medications

Acute/Short-Term Therapy Drugs Purchased at a local pharmacy:

  • Supply of 30 days or less 
  • Limited to four 30-day fills of same prescription*(some exceptions may apply)

Member copays:

  • Generic, $15
  • Brand-name formulary, $30
  • Non-formulary**, $60

Maintenance/Long-Term Drugs
Express Scripts Mail Order Service:

  • Supply of 31 days or more
  • Up to 90-day supply
  • Unlimited refills as prescribed by your physician

Member copays:

  • Generic, $25
  • Brand-name formulary, $60
  • Non-formulary**, $120

Maintenance/Long-Term Drugs Purchased at local pharmacy:

  • Supply of 31 days or more up to 90-day supply
  • Supply of 30 days or less, starting after 4th fill
  • Unlimited refills as prescribed by your physician

Member copays:

  • Generic, $25 or 50% of cost, whichever is greater
  • Brand-name formulary, $60 or 50% of cost, whichever is greater
  • Non-formulary**, $120 or 50% of cost, whichever is greater

 *  After four consecutive fills within 120 days of the same prescription at your local pharmacy, starting with the fifth fill, you will pay 50% of cost or the appropriate mail order copay for long-term therapy drugs, whichever is greater.
** A formulary is a list of prescription medications chosen by Express Scripts for their ability to be clinically and cost effective.

Note:  A new prescription is required every 12 months from the physician.

 

Mental Health and Substance Abuse Care Benefits

Administered by Cigna Behavioral Health: 866-726-5267


Network Cost

Non-Network Cost

Individual deductible
$0

$0

Family deductible

$0

$0

Coinsurance

0%

0%

Outpatient Individual & Group therapy

Option A: $25 copay

Option B: $25 copay

Option C: $30 copay

Option D: $35 copay

Option A: $50 copay

Option B: $50 copay

Option C: $60 copay

Option D: $70 copay

Outpatient Psychological & Lab testing

0%

0%

Emergency Room Visit
      $120 copay     
(waived if admitted)  
$120 copay
(waived if admitted)

Inpatient care

0%

0%

Other Expenses                           
    0%       0%

 

Dental Care Benefits

Administered by Cigna Dental: 800-244-6224

 

Network BenefitsMember Pays…

Preventive Dental Care
Oral exam (two per calendar year), cleaning (two per calendar year), two sets of bitewing x-rays per calendar year, one set of full mouth or panoramic x-rays every three years, fluoride application (one per calendar year for persons under age 19), sealants (limited to posterior tooth, only for persons under age 16, one treatment per tooth every three calendar years), space maintainers (limited to non-orthodontic treatment), emergency care to relieve pain, palliative (emergency) treatment, and dental x-rays required for the diagnosis or treatment of a dental defect, injury, or disease.

$0

Basic Dental Care
Fillings, extractions, inlays, onlays, crowns, root canal, therapy, bridgework, initial installation or replacement, of complete or partial dentures, denture adjustments or repairs, periodontal scaling and root planing, osseous surgery, and anesthesia.

Temporomandibular joint (TMJ) disorder will be included under Basic Dental Care only if deemed by CIGNA Dental to be a dental expense instead of medical expense.

Replacement of a bridge, crown, or denture will be covered only if it has been more than five (5) years since the date originally installed unless (A) such replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth, or (B) the bridge, crown, or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while the person was a member or enrolled dependent.

20% after deductible*

Oral Surgery
Any incision or excision procedure on the gums or tissues of the mouth performed in connection with the extraction or repair of teeth, including related services if otherwise included as an eligible charge under the plan. Implant services will be considered to be oral surgery. If the charges for implant services are not deemed to be medically necessary by Cigna Dental, the Alternate Benefit provision will be applicable for the prosthetic being placed on the implant and no reimbursement will be made towards the charges for placement of the implant. 
20% after deductible*

Orthodontia
Treatment and installation of orthodontic appliances for correction of irregularities in tooth position and jaw relationship (for adults and dependent children). 

50% after deductible*

*Annual dental deductible is $100 per individual/$300 per family unit.

The annual maximum for basic dental care is $1,500 per person. Preventive care is not subject to the annual benefit maximum.

The lifetime maximum for orthodontia is $1,500 per person.

 

Preventive Care

Medical Care
If provided or authorized by a network physician, expenses for routine physical exams, well baby & child care, immunizations, mammograms, etc., are covered at 100%.

NOTE: Effective January 1, 2013, one manual breast pump per pregnancy/delivery will be covered as a preventive service at 100% under the Concordia Health Plan Options A – E and HDHP.

To be an eligible preventive service covered at 100%, the breast pump must be purchased through the medical benefit from a participating Durable Medical Equipment (DME) provider – not through the pharmacy benefit or at a retail store. While Blue Cross does not require a prescription to process a DME claim for a breast pump, the DME provider may require a prescription from the member’s doctor, so it would be best to obtain the prescription before contacting a DME provider. The breast pump can be purchased prior to delivery and up to six- months postpartum.

To find a Blue Cross participating DME provider, click here.

You'll click on "Find a Doctor," and then "Search" in the left menu bar. On the next page, choose "Support and Other Services." The Plan or Network is National BlueCard PPO. Enter the rest of your search criteria (i.e., city/state or Zip code and range of distance you are looking in). Finally, under “Other Service Type,” choose “DME/Medical Supplies.”

Blue Cross Blue Shield Preventive Care Guidelines

The Concordia Health Plan (CHP) does not provide coverage under Preventive Care Services for the following:
 
• Contraceptive methods and counseling
• Counseling for Domestic Violence
• Counseling for HIV

For members in a CHP PPO Option, Counseling for Domestic Violence and HIV are covered under the CHP behavioral health benefit administered by Cigna Behavioral Health. For members in Option HDHP, behavioral health benefits are administered by Blue Cross Blue Shield of Minnesota.

Blue Cross Blue Shield Preventive Care Recommendations

The above guidelines are provided as recommended preventive care, however, your physician should always check with the network manager to verify coverage.

If care is secured from a physician who is not in the managed care network, charges for such care are not covered.

If a preventive doctor’s visit or screening reveals a potential medical concern, the purpose of your visit, for billing purposes, could change from preventive care to medical treatment or diagnosis.

Concordia Plan Services has prepared a preventive care notice that you can share with your doctor, explaining the preventive care billing process. We encourage you to print this notice and take it with you to your preventive care visits. 

Provider Preventive Care Notice


Dental Care

Expenses for a routine dental checkup, including teeth cleaning and x-rays, are reimbursed at 100% (but no more than two exams and/or cleanings every calendar year and no more than two sets of bitewing x-rays in a calendar year).

Good dental care may be linked with a decreased risk of pre-term birth. Cigna Dental has provided an informational flyer on the importance of good oral health for pregnant women.


Shingles Vaccine Coverage
The shingles vaccine is covered at 100% under preventive care with a network PPO provider for Concordia Health Plan (CHP) members age 50 and older. It is also covered at 100% by Express Scripts if administered by the pharmacist at a network pharmacy. The Food and Drug Administration (FDA) lowered the age of who could receive the vaccine without requiring a prescription from 60 to 50 in March 2011. 


Seasonal Flu Vaccine Coverage

Express Scripts
During flu season (from October 1 through June 1), members can present their Express Scripts prescription drug card at a retail pharmacy that participates in the Express Scripts vaccine network and receive the seasonal flu vaccine. (This includes the FluMist nasal flu vaccine spray as well as the shot.) There would be no up-front cost to the member, and it would be covered at 100% by the Concordia Health Plan.

If a member receives the vaccine at a pharmacy that does not participate in the Express Scripts vaccine network, the member would pay for the costs associated with the vaccine and submit a manual claim to Express Scripts for reimbursement.

Blue Cross Blue Shield of Minnesota
If a member receives the seasonal flu vaccine at a participating provider’s office, it would be covered at 100% under all of our medical plans with BCBS, and the member would not have to pay up front or submit any paperwork.

If a member receives the vaccine at any other provider (including community clinics), the member should pay for any costs associated with the vaccine and submit a manual claim to Blue Cross for reimbursement. When submitting a claim, the member should include a receipt showing the name and address of the provider, the date of service, the type of service (seasonal flu vaccine), and the charge for the service.