BlueCross/BlueShield PPO (www.carefirst.com)
The PPO plan allows you to see any doctor in their network – including specialists – without a referral. CareFirst has a national network of providers; however, you may use any licensed provider you choose. There are two levels of coverage under the plan. Your level of coverage is determined each time you receive care, depending on whether you use a network or non-network provider. Your out-of-pocket costs under both levels of coverage may include office visit copayments, deductibles and coinsurance.
If you have questions or need assistance, please contact the PSA Benefits Hotline at 1-877-716-6618 or email Loyola@psafinancial.com.
In-Network: This level of benefits applies when you use a physician, specialist or other provider who is a member of the BCBS PPO network. By utilizing In-Network providers, you will pay lower copayments, deductibles and coinsurance than you will using Out-of-Network providers. Please note that there is no penalty for seeking specialist care without a referral, thus providing more freedom and easier access to care.
Contraceptive and sterilization services and procedures are not covered under any of the Loyola sponsored medical plans. These services are available directly from CareFirst. Access the benefit by providing your insurance card as you normally do to an in-network pharmacy (services and procedures will not be covered out-of-network). CareFirst will in turn arrange payment directly to the pharmacy. Contact CareFirst Member Services at 1-800-628-8549 for additional information.
Out-of-Network: This level of benefits applies when you use a provider who is not a member of the BCBS PPO network. You will be covered, but you will pay higher deductibles and coinsurance than you will using In-Network providers. In addition, you are responsible for any amounts incurred in excess of the "allowed amount". "Allowed amount" is the pre-determined usual, customary and reasonable charges for a particular service. Charges may vary from one geographical area to another. Additionally, Out-of-Network providers may require you to pay at the time of service and you will have to file a claim with the Plan in order to be reimbursed.
Traveling outside of the service area? Read about BlueCard Worldwide before your trip. A representative is available to answer your questions 24 hours a day, seven days a week at 1-800-810-2583 or collect call at 1-804-673-1177.
Finding a Doctor
The BCBS PPO network is a national network of providers. To locate a medical provider, go to the on-line directory at www.carefirst.com, or contact member services by phone at 1-800-626-0173.
Mental Health/Substance Abuse
The Plan provides inpatient, intermediate and outpatient care. There is a network of Mental Health Preferred Providers for mental health and substance use disorder services. If a Member chooses one of these Mental Health Preferred Providers, the cost to the Member is lower than if the Member
chooses a Mental Health Non-Preferred Provider. The Schedule of Benefits lists payments as either “In-Network: Mental Health Preferred Provider” or “Out-of-Network: Mental Health Non-Preferred Provider” (United Behavioral Health), but you may go to any provider. Benefits are paid differently, depending on whether you use network or non-network providers.
Prescription Drug Plan
Participants in the plan automatically participate in the prescription drug plan administered by CVS CareMark. You can choose between retail and mail order options. If you are taking maintenance prescription medication, we encourage you to investigate the mail order option. Members can sign up for mail order today by calling CareFirst Pharmacy Services at 1-800-241-3371, through My Account, or by completing the Mail Service Pharmacy Order Form.
Filing a Claim
When you use a network provider, that provider will submit your claim to United Healthcare on your behalf. United will pay the provider as determined by plan rules and send you an Explanation of Benefits (EOB) which details for you the total amount billed by the provider, the amount that United paid,
and the amount for which you are liable. Your provider will send you an invoice for the amount for which you are liable (if any). When you use a non-network provider, your provider may require you to pay the full bill at the time the service is rendered. You should then submit a copy of your invoice to
CareFirst, along with a Major Medical Claim Form. You will be reimbursed for any amount determined to be payable to you by the Plan.
BCBS PPO Benefit Resources: