PPO. Preferred Provider Organization. Flexible. Easy to use. No Referrals.

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1 PPO Preferred Provider Organization Flexible. Easy to use. No Referrals. PPO is issued by Capital Advantage Assurance Company (pending approval of its licensing application) or by Capital Advantage Insurance Company, subsidiary companies of Capital BlueCross.

2 Flexible. Easy to use. No Referrals. Welcome to PPO PPO is a very flexible plan with one of the largest provider networks in our 21-county service area. Your employer has selected a plan that gives you the freedom to choose the providers you want to see. However, you maximize your benefits and have the lowest out-of-pocket costs when you use a participating provider. You also have access to providers outside our 21-county service area through the BlueCard network. BlueCard providers are also covered at the highest benefit level. Most likely, you already have a family physician that treats you for most of your care. With over 11,000 providers in Central Pennsylvania and the Lehigh Valley in our network, there is a good chance your current doctor already participates with Capital BlueCross. With some plans, you have to use a participating provider to receive any level of benefits. With PPO, you can even see doctors or hospital providers who are not in the network and receive some level of coverage, but you will be required to pay more of the cost. When you use a PPO provider, there are no claims to file. Your provider takes care of the paperwork for you. If you choose to see a nonparticipating provider, you may have to submit the bill and claim form to be reimbursed for eligible expenses.* Your PPO Plan allows you to use any of our providers in our 21-county service area. To find a participating provider in the Capital BlueCross 21-county service area, search our on-line directory at With PPO, you have access to thousands of BlueCard participating doctors and hospitals outside our 21-county service area, across the country, and around the world. To find a BlueCard participating provider anywhere outside our service area, you can search the Blue Cross and Blue Shield Association s online directory at You can also call BLUE, or, when traveling outside of the country, you can call collect to for assistance 24 hours a day, seven days a week. Alpha Prefix: EBH *Reimbursement to member based on allowed charges after meeting a deductible and other cost-sharing amounts.

3 If you re looking for more, you ve come to the right place! Your benefits Your PPO plan covers adult and pediatric preventive care and other important health care services. Services may be subject to copayments, coinsurance, and deductibles. You do not need a referral to see a specialist; however, some services require preauthorization. Please refer to your Certificate of Coverage and/or Benefit Highlight Sheet, or check your benefits online by logging in to Preventive care*: Routine physicals Annual gynecological exams Annual mammograms for women 40 and over Childhood immunizations Select screenings Other covered services*: Doctor office visits for illness or injury Maternity and newborn care Emergency care and emergency ambulance service Lab tests and X rays Inpatient and outpatient hospital services Disease management programs Physical, occupational, speech, and manipulation therapies Mental health care Drug and alcohol treatment Home health care Skilled nursing-facility care * The above listing is not a complete summary of benefi ts. Please refer to your Certificate of Coverage and benefit highlight sheets for more details.

4 Your Share of the Cost The term cost-sharing refers to the amount of money you contribute toward the cost of your medical services. Your contribution typically includes deductible and coinsurance. For nonparticipating providers, after you have met your deductible, you may be responsible for coinsurance AND you may pay any difference between what the provider charges and what Capital BlueCross pays. Since cost-sharing amounts vary depending on your specific coverage, it is important that you refer to the Summary of Cost Sharing and Benefits section of your Certificate of Coverage. Definitions: Annual Deductible: A specified dollar amount that you or your entire family must incur each benefit period before benefits are paid under your coverage. Coinsurance: The percentage you are required to pay based on the total amount allowed by Capital BlueCross for a specific service. Out-of-Pocket Maximum: The maximum amount of coinsurance that you or your entire family must pay during a benefit period. Participating Provider: A health care facility provider or a professional provider who is properly licensed, where required, and has a contract with Capital BlueCross to provide benefits under your coverage.

5 Your Member Identification Card (ID card) Preauthorization Your ID card is the key to accessing the benefits provided under PPO. ID # EBH Group # EBH361 Suitcase Symbol Show this card each time you seek medical services. The following is important information about the ID card: Preauthorization: A clinical program in which our nurses work with physicians to approve and monitor certain health care services prior to the delivery of services. The purpose of preauthorization is to ensure that all members receive medically appropriate treatment to meet their individual needs. Certain medical and therapy services and all nonemergency inpatient hospital admissions require preauthorization. Refer to the Preauthorization Program attachment of your Certificate of Coverage for more information. Suitcase Symbol: This symbol lets you know that your coverage includes BlueCard and BlueCard Worldwide. With both programs, you have access to BlueCard participating providers nationwide and worldwide. The back of the ID card has important information such as: Toll-free telephone numbers. General instructions for filing claims. Emergency care information. Remember to destroy old ID cards and use only your current ID card. Please contact Customer Service at the phone number that appears on your ID card if any information on your card is incorrect or if you have questions. Please refer to your Certificate of Coverage for a detailed description of all benefits, limitations, definitions of terms, and exclusions that apply to your plan.

6 When you take the time to become a better health care consumer, you are doing your part to help keep health care affordable. And as a member of Capital BlueCross, you will have access to the information and tools to assist you in making better decisions about your health and well-being. Great ways to become a better health care consumer... Register for a secure personal account at If you haven t already set up a secure personal account, register on our website to establish a user ID and password. Your secure account is a valuable tool that can help you make the most of your health care benefits. Here s how: When you login to you can Check the status of a claim. Compare hospital quality and treatment costs. Print a temporary proof of coverage. Access the Simply Well SM member newsletter. View your Explanation of Benefits (EOB) for the past two years. And much more! Take your FREE Better Health Works Personal Profile. The Better Health Works Personal Profile starts by asking you questions about yourself and the way you live. Based on the answers you provide, you ll receive customized recommendations for your health situation. And to help you follow through on those recommendations, we provide you with the support you need to make positive health changes. For more information, go to or call (TTY: ).

7 Call Nurse Line 24 hours a day, 7 days a week. When your doctor is out, Nurse Line is always in. Nurse Line is staffed by experienced Registered Nurses who provide information and support for any health-related concern, at no cost to you. Call BLUE (TTY: ). Blue365. At Capital BlueCross, we want to help you take care of your health through all the stages of life. With this in mind, we offer Blue365 to encourage members and their families to get up, get out and get active. Blue365 offers discounts on gym memberships, fitness apparel, and other products and services. Practice preventive care. Use your preventive care benefits: physical exams, screenings, and immunizations to detect potential health problems early. You ll find our adult and pediatric Preventive Health Guidelines on our website. Take control of the quality and cost of your health care. Use MyCare Advisor SM to research and compare average cost and quality information for many of the most common elective surgical and treatment procedures to maximize your health care dollar. Log in to to access this valuable tool before deciding where and how much you spend on your procedure.

8 Contact Us (TTY: ) Monday through Friday 8 a.m. to 6 p.m. Look for more ways to become a better health care consumer. Be sure to come back often to see what s new. /capbluecross /capbluecross Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. GR-S indd (10/17/2012)