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FAQ

Personal Choice^® PPO

What is a Preferred Provider Organization (PPO)?

What is the meaning of in-network/out-of-network benefits?

Can you tell me if my doctor or hospital is in the Personal Choice network?

How are emergencies covered?

How are prescription drugs covered?

What is a Preferred Provider Organization (PPO)?
PPOs are a combination of fee-for-service and HMO programs. They offer the preventive benefits of an HMO and the freedom of traditional insurance to choose the doctor or hospital you want.

PPOs give you a financial incentive to use in-network (preferred) providers. When you do, a greater portion of the cost of services is covered. But you can opt for out-of-network doctors or facilities and still receive some coverage. When you receive care out-of-network, you will be responsible for a deductible and coinsurance. In addition, out-of-network, non-participating providers may bill you for the differences between the plan allowance and the provider’s actual charge.

Unlike an HMO, a PPO does not require you to coordinate your care through a Primary Care Physician or obtain a referral to see a specialist.

What is the meaning of in-network/out-of-network benefits?
When you use a provider that participates in the Personal Choice network or the BlueCard^® PPO program, they are considered in-network. Providers that do not participate in the Personal Choice network or BlueCard PPO are considered out-of-network, and your benefits are reduced.

Can you tell me if my doctor or hospital is in the Personal Choice network?
To find a participating provider, use the online provider search. You can also call Personal Choice Member Services at 215-557-7577 or 1-800-626-8144 (outside Philadelphia).

How are emergencies covered?
An emergency is a medical condition manifesting itself in acute symptoms of sufficient severity that the absence of immediate medical attention could result in serious medical consequences or place your health in serious jeopardy. If you are experiencing symptoms that might reasonably indicate such a condition, then you may need emergency care and should go immediately to the emergency department of the closest hospital. Health concerns of a pregnant woman also may extend to her unborn child. If you believe your situation is life threatening, you should call 911.

Try to notify your personal physician within 48 hours of being treated, or as soon as possible if follow-up care is needed.

Emergency services are paid according to your in-network level of coverage. If you are admitted to an out-of-network hospital, you must notify us within two (2) business days, or as soon as reasonably possible. If you are not admitted to the hospital, you are not required to call us.

How are prescription drugs covered?
In order to provide members with the most value, our pharmacy benefits manager, FutureScripts^®, administers our prescription drug benefits. FutureScripts pharmacies have agreed to charge a discounted price for drugs when you show your Personal Choice identification card. More than 60,000 retail pharmacies nationwide participate in the FutureScripts network.

The FutureScripts network includes many neighborhood pharmacies, as well as large chain stores. When you go to any participating pharmacy, simply show your Personal Choice identification card. The pharmacist will charge you the Personal Choice prescription program negotiated discount price. The pharmacist will file a claim with us on your behalf, eliminating paperwork for you.

What happens if I do not use a participating pharmacy?

• Pay the pharmacist for your prescription and obtain an original pharmacy receipt that includes the drug’s National Drug Control (NDC) number and the price that you paid. A cash register slip or credit card receipt is not acceptable.
• Complete a FutureScripts Prescription Reimbursement Claim Form, attach your receipt, and mail it to the address on the form. To obtain claim forms, call FutureScripts Customer Service at 1-888-678-7012.