Benefits

      

Lafayette College PPO - Capital Blue Cross
(Preferred Provider Organization)


Plan Highlights: Basic Coverage
Plan Highlights: Preventive Care
Plan Highlights: Prescription Drugs 		Handbook
Express-Scripts Website
Frequently Asked Questions
 

The Capital Blue Cross PPO (Preferred Provider Organization ) plan is a fully-insured plan administered by Capital Blue Cross. Locally, the plan utilizes the "Capital Blue Cross PPO" network of hospitals and medical providers. In addition, if you wish to obtain medical services outside of the area, the Blue Card program is a nationwide provider network you may use for out-of-area services. A current listing of providers can be accessed on-line at www.capbluecross.com.

Plan Design

1. PPO In-Network Services:
You may utilize any Capital Blue Cross PPO Network provider on an "in-network" basis. If you visit a participating provider, the office visit copayment for both primary care physicians and specialists is $15. Referrals are not required for specialist visits. The $15 office visit copayment also applies to in-network preventive care, out-patient psychological services, chiropractic, and out-patient physical therapy services. Please refer to the "Plan Highlights" for more information.

Under the Capital Blue Cross PPO Plan, there is an in-network individual deductible of $150 (maximum 3 per family per calendar year). This deductible is applied to any in-network charges that are not part of an office visit copayment (for example, x-rays, CAT scans, lab work, in-hospital admissions). The in-network deductible does not apply to some in-network procedures, such as emergency treatment, ambulance service for emergency care, and certain preventive care procedures. After the in-network deductible has been satisfied, you are responsible for an in-network coinsurance of 10% of the allowable charge (the College PPO Plan pays the remaining 90%). The maximum annual individual in-network coinsurance amount you will pay, excluding the $150 deductible, is $500 per benefit period (maximum 3 per family per calendar year). Thus, the annual total maximum in-network exposure per person (maximum 3 per family) is $650. Thereafter, the plan will pay 100% of eligible provider charges for the remainder of the benefit period.

2. PPO Out-of-Network Services:
You may also utilize the services of an "out-of-network" provider. The out-of-network deductible and coinsurance is applied for out-of-network services. Out-of-network preventive care, out-patient psychological services, chiropractic, out-patient physical therapy services, durable medical equipment and injections are also subject to the out-of-network deductible and coinsurance. Please refer to the "Plan Highlights" for more information.

Because the Blue Cross network is so large (countrywide) the utilization of non-network services is expected to be minimal. The out-of-network individual deductible is $500 (3 per family maximum per calendar year). After the out-of-network deductible has been satisfied, you are responsible for an out-of-network coinsurance of 30% of the allowable charge (for most services), the College PPO Plan pays the remaining 70% of the allowable charge. The annual individual out-of-pocket coinsurance maximum amount, excluding the $500 deductible, is $1500 (maximum 3 per family per calendar year). Thus, the annual total maximum out-of-network exposure per person (maximum 3 per family) is $2,000. Thereafter, the plan will pay 100% of the Capital Blue Cross allowance. Eligible out-of-network facilities are paid utilizing a 50% coinsurance. Please note that a non-participating provider can balance bill you the difference between his billed amount and the Blue Cross allowable amount in addition to any applicable deductibles and coinsurance.

3. Emergency Care:
There is a $50 emergency room copayment (waived if admitted); the in-network deductible does not apply to this service.

 

4. Prescription Plan Deductible and Copayments:
Prescriptions are processed through Express Scripts. There is a $100 individual deductible (maximum 3 per family per calendar year) applied to the prescription coverage. After the deductible has been satisfied, the copayments for generic, brand name formulary, and brand name non-formulary are applied.

The copayments for up to a 30-day supply of a prescription medication from a participating pharmacy (retail) are $10 generic, $15 brand name formulary, and $30 brand name non-formulary. Non-formulary drugs are brand name drugs that have not been proven to be as effective as formulary drugs or are of equal effectiveness but are more costly. The copayments for a 90-day supply of prescription medication (using the mail order plan) are $20 generic, $30 brand name formulary, and $60 brand name non-formulary.

When a prescription order is filled with a generic drug, the member is responsible for the applicable copayment. When a prescription order is filled with a brand drug and/or no Generic Drug equivalent is available and/or state law requires that a brand drug be dispensed and/or the prescription order states "Brand Medically Necessary" (or substantially similar language), the member is responsible for the applicable copayment.

When a Prescription Order is filled with a brand drug and a generic drug equivalent is available to treat the member's condition, the member must pay the difference in the cost between the brand drug and the generic drug in addition to the applicable copayment.

Capital Blue Cross Telephone Numbers and Websites:

1-800-962-2242 (Capital Blue Cross Customer Service - for general information or assistance with medical/prescription claims.)

1-800-810-BLUE (To locate Participating Providers)

www.capbluecross.com (Capital Blue Cross Website: to locate Participating Providers - click the PPO/PPO Plus option)

www.bcbs.com (To locate providers out of our area.)

www.express-scripts.com (For prescription information.)

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