BlueChoice Option Healthcare Plan POS
In-Network Benefits for BlueChoice Option
Our BlueChoice Option POS in-network benefits work the same as our BlueChoice HMO plan. Review the BlueChoice HMO
section of this ERG for more information. If the procedures for in-network benefits are not followed, out-of-network benefits will apply. Please read below to learn more about how BlueChoice Option POS works if your employees choose to receive care out of network.
Out-of-Network Benefits for BlueChoice Option
Eligible benefits will be paid at the out-of-network level if your employees choose to receive care from physicians or providers who are not in the BlueChoice Option network. This rule also applies when your employees visit network physicians or facilities without referrals from their selected PCP. The out-of-network benefits are subject to an annual deductible and higher level of coinsurance.
The Out-of-Network Calendar Year Deductible
Before we can begin to pay benefits, your employees must meet any required deductibles. Deductible requirements are stated in the out-of-network summary of benefits section in your Certificate Booklet.
Percentage Payable Out-of-Network
Any out-of network portion paid by your employees will be applied to their out-of-pocket maximums. Once your employee reaches the out-of-pocket maximum (plus any required deductible), we pay 100% of covered expenses for the remainder of the calendar year. However, the out-of-pocket maximum benefit does not apply to:
| PCP or referred specialist office visit copays |
| Prescription drug copays |
| Emergency room copays |
The above services are never paid at 100% even after the out-of-pocket maximum has been met.
Out-of-pocket maximums are accumulated separately for in-network (if applicable) and out-of-network providers.
Out-of-Network Preventive Care Benefits
The following services are covered out-of-network, subject to your employees’ deductibles and out-of-pocket requirements. Click here
to access the frequency of these health care services as noted in our Preventive Health Guidelines.
| Mammograms |
| Pap Smear |
| Chlamydia Testing |
| Prostate Antigen Test |
| Child Wellness Services |
Out-of Network Pre-Admissions
Your employee, the physician or the hospital must obtain approval for all hospital admissions to a non-preferred hospital. If a member is hospitalized and preauthorization was not obtained, all charges will be denied. The member will be responsible for all hospital charges. Pre-admission certification is not a guarantee of payment.
Waiting Periods and Pre-existing Limitation Periods
Please have your employees review their Certificate Booklet for more information.
Processing Out-of-Network Claims
When your employees use out-of-network providers, they are responsible for submitting claims for reimbursement. Members should be sure that their name, group and member number are accurately filled in on the claim form. The group administrator should have a copy of the Member Health Expense Report for employees to file. Click here
to access the form electronically. The reimbursement will be based on the usual, customary and reasonable (UCR) amount allowed for the services that were rendered.
Prescriptions Written by an Out-of- Network Physician
The out-of-network coinsurance and deductible will apply if an out-of-network physician writes a prescription for a drug listed on the Preferred Drug Formulary. However, if an out-of-network physician writes a prescription for a non-formulary drug, no coverage is available.