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Your Health Benefits

Anthem Blue Cross and Blue Shield PPO Plan

About Anthem Blue Cross and Blue Shield PPO

With Anthem Blue Cross and Blue Shield PPO you have freedom of choice to receive medical care from licensed physicians and providers in and out-of-network. How your care is covered and how much you pay out of your own pocket depends on whether the expense is covered and whether you choose a participating provider. (See your Enrollment Guide for details.)

How the Plan Works

You and your covered family members can receive care from doctors and facilities that belong to the Anthem Blue Cross and Blue Shield network. These providers are called in-network providers. When you need care, you have a choice. You can select a doctor or facility that belongs to the network or one that does not belong (an out-of-network provider).

  • If you use an in-network provider, you'll pay less out of your own pocket for your care. You won't have to fill out claim forms, because your in-network provider will file claims for you.
  • If you use an out-of-network provider, you'll pay more out of your own pocket for your care and you'll be required to file your own claims.

You may find in-network providers by using the BlueCard Doctor(R) & Hospital Finder button on the left.

The Summary of Benefits chart shows how the plan's level of coverage differs when you use in-network versus out-of-network providers. In most cases, you save money when you use in-network providers.

Remember, you don't need a referral to visit a specialist. Just make an appointment and show your ID card when you go to the doctor. Keep in mind that the plan will pay more and you'll pay less when you visit an in-network specialist. Call the Customer Service line at 1-800-810-2583 or visit the Anthem Blue Cross and Blue Shield online directory to find specialists in your area who belong to the Anthem Blue Cross and Blue Shield network.

Pre-Existing Condition Limitation Applies to the Anthem Blue Cross and Blue Shield PPO Plan

This plan imposes a pre-existing condition exclusion. This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period preceding the effective date of coverage. The pre-existing condition exclusion does not apply to pregnancy or to a dependent child (under the age of 19) who is enrolled in the plan within 31 days after birth, adoption or placement for adoption.

This exclusion may last up to 12 months from your first day of coverage. However, you can reduce the length of the exclusion by the number of days of your prior "creditable coverage". Most health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month exclusion by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, the plan will help you obtain one from your prior plan or issuer. There are also other ways that you can show you have creditable coverage. Please contact Employee Benefits if you need help demonstrating creditable coverage.

More information is available in the Summary of Benefits (PDF).

Anthem Blue Cross and Blue Shield PPO Q&A

Can I visit a specialist without a referral from a primary care physician?

Yes. You don't need a referral to visit a specialist. Just make an appointment and show your ID card when you go to the doctor. Keep in mind that the plan will pay more and you'll pay less when you visit an in-network specialist. Call the Customer Service line at 1-800-810-2583 or visit the Anthem Blue Cross and Blue Shield online directory to find specialists in your area who belong to the Anthem Blue Cross and Blue Shield network.

What happens if I have an emergency and receive care from an out-of-network provider?

If you have a true emergency and use an out-of-network provider, benefits will be paid at the in-network level – providing your illness or injury meets the plan's definition of an emergency.

If I have a child living outside the network area, will the plan pay in-network or out-of-network benefits?

If you have a child attending school or living away from home in an area not served by the Anthem Blue Cross and Blue Shield network, he or she has a choice. He or she may travel to an in-network provider and receive in-network benefits or visit an out-of-network provider and receive out-of-network benefits.

Do I need a referral to visit a specialist?

A referral is not needed to visit a specialist. Just make an appointment and show your ID card when you go to the doctor. Keep in mind that the plan will pay more and you'll pay less when you visit an in-network specialist. Use the online directory at http://www.bcbs.com to find specialists in your area who belong to the Anthem Blue Cross and Blue Shield network.