Frequently Asked Questions

Benefits

I just got coverage. What do I do now?

You can do a few things right away to get the most from your health plan:

• Put your new member ID card in your wallet or in another safe place.
• Sign up for Blueprint Portal. It's our members-only website, where you can estimate treatment costs, review and rate doctors you have seen, view your claims and more.
• Use our Find Care tool on Blueprint Portal to find a primary care provider (PCP). Your PCP is the doctor you should see first for routine medical care. You can change your PCP at any time. Please let us know if you do.
• Schedule an annual visit with your PCP. It's a good opportunity for your doctor to get to know you.
• Download our mobile app. It gives you instant, on-the-go access to your electronic member ID card. With our mobile app, you can access our Find Care tool, along with maps, live customer service support and more.

What does my health plan cover?

There are several ways to find out what your health plan covers:

• Customer Service - Call them using the telephone number on the back of your member ID card.
• Blueprint Portal - Sign in to this members-only website to review your health plan benefits.
• Statement of Benefits - Review the statement of benefits you received in the mail when your coverage began.

What is the difference between in-network and out-of-network benefits?

Your coverage is based on pricing arrangements we have with our network of healthcare providers. Getting care from providers in your plan’s network almost always saves you money. Generally, in-network benefits and services are provided at lower rates than out-of-network benefits and services. That’s because we contract with most doctors and hospitals (in-network providers), but don’t have contracts with others (out-of-network providers). Out-of-network providers usually charge more, so you usually end up paying more.

If you receive care from a doctor or hospital that is out-of-network, you still benefit from having insurance. However, you won’t get the lower cost that we negotiate with in-network providers, meaning you will pay more out-of-pocket.

Any time you get a referral to a specialist, it is good to make sure he or she is in-network. You can call customer service to find out if a doctor or hospital is in-network, or you can use the Find Care tool.

What's the difference between a preventive test and a diagnostic test?

Preventive screenings look for health conditions or diseases before there are any signs or symptoms. Diagnostic tests are run when your doctor knows you have a health problem but needs to know the cause or extent. Preventive screenings, when run as part of an annual wellness visit, often are covered at no cost to you. If you need diagnostic tests, you will likely pay for a portion of the test, according to your benefits (deductible, copay, coinsurance, etc.).

Why do I get a PHS or an EOB?

Depending on the coverage you have, you'll receive either a Personal Health Statement (PHS) or an Explanation of Benefits (EOB) each time you visit a doctor, so you can keep track of your healthcare spending. It's not a bill. It is a guide for how to review a bill if your doctor sends you one. You also can see your claims history in our secure, members-only website Blueprint Portal.

Cost

How do premiums, deductibles, copays and coinsurance work?

A premium is the fixed amount you and/or your employer pay periodically for your health insurance (health plan) coverage. People with coverage through their employer may share in paying a portion of their premium through payroll deduction.

A deductible is the amount you pay for healthcare before your health plan begins to make payments. For example, if your deductible is $1,000, your health plan will begin paying once you’ve paid $1,000 toward “allowable” charges, not the billed charges. An “allowable” charge is the amount your health plan agrees to pay for a particular healthcare service. The amount reflected on a healthcare provider’s bill may be more, but your deductible is based on the “allowable” charge. Also, you may have a deductible for each person on your policy and one for your family as a whole.

Copayments (copays) are a fixed amount you pay, usually at the time of a medical service. Copays are separate from, and do not count as part of, your deductible. However, they do count toward your out-of-pocket maximum, which can help if you have high medical expenses during a calendar year. Your copay can vary, depending on the type of service you receive (for example, a copay for seeing a specialist may be more than a copay for a primary care visit). You also may have a copay when you get a prescription filled.

Coinsurance is the percentage of the cost you are responsible to pay for healthcare services, after your deductible has been met. For example, you may pay 20% for a service, and your insurance may pay 80%.

Is my copay applied to my deductible?

No. Copays do not count as part of your deductible.

Why do I pay a deductible when I’m already paying a premium?

A premium is the amount you and/or your employer pay for health insurance coverage. A deductible is the amount you pay for medical costs before your health plan begins to make payments. Deductibles are a form of cost sharing, and they exist to help make health coverage more affordable. If your deductible were eliminated, unless healthcare costs were controlled in some other way, chances are, your price to have health insurance (your premium) would be higher

Why does my premium go up, even if I don’t have any claims?

The cost of healthcare keeps increasing – much more than other costs. This high healthcare inflation affects premiums. We are constantly working to find ways to hold down the cost trend for everyone. We have focused on reducing low-value services in the healthcare system, using technology to create efficiencies, promoting transparency and rewarding evidence-based care. To understand how health insurers determine annual premiums, see the question "How are premiums determined?" below.

How are premiums determined?

Each year, we develop profiles of members, based on age and gender. We then look at claims data to figure out how much that type of member will cost, based on the average number of doctor visits and health risks we see for members of the same age and gender. Using those profiles, multiplied by the number of covered members, we estimate what the costs will be for the upcoming year. Then we find an average cost per member or family.

How do out-of-pocket maximums work?

Huge medical expenses can be devastating. That’s why out-of-pocket maximums are put into your health plan. If you or a family member has a health crisis, and you reach your out-of-pocket maximum for the calendar year, your insurance will cover you at 100% for the rest of that year. The out-of-pocket limit includes your deductible, coinsurance and copay amounts. The out-of-pocket limit does not include premium payments or charges for services that are not covered.

For example, if your out-of-pocket maximum is $10,000, when you reach this amount, your insurance will cover your services at 100%. Please note that there are separate in-network and out-of-network limits for out-of-pocket maximums. This means you may meet your out-of-pocket maximum for in-network services, but if you receive out-of-network services and have not met that deductible, you still may receive a bill.

Health Savings Accounts (HSAs)

What is a healthcare savings account?

A health savings account is a special tax-exempt fund you can use to pay for approved healthcare costs. You or your employer can deposit money into this account. An HSA is a way for you to pay for your qualified healthcare expenses and save for future expenses on a tax-free basis.

What are the rules about health savings accounts?

Health savings accounts have rules for contribution limits, minimum deductibles, out-of-pocket maximums and unqualified medical expenses that can change yearly. To learn more about HSAs, go to the healthcare.gov glossary entry on HSAs.

Pharmacy

How do I know if my prescription drug is covered?

You can view our list of covered drugs, also called a formulary. Our formulary shows all of the drugs we cover under all of our health plans. View your specific health plan to see which drugs we cover under that plan.

How can I find a pharmacy?

You can use our pharmacy locator to find a pharmacy. You can also call the customer service number on the back of your member ID card.

How do drug tiers work?

Drug tiers represent different levels of cost and can save you money on your medications. You pay the least for medications in tiers 1 and 2, which usually are generic drugs. All generic drugs are approved by the Food and Drug Administration (FDA) and are scientifically proven to be just as effective as brand-name drugs. In fact, they typically are the same medication as their brand-name equivalents, with identical active ingredients. Patents for brand-name medicines give drug companies the ability to market a drug for a period of time without direct competition. When these patents expire, generic versions (usually called by their scientific names) can come on the market, often at much lower prices. You will pay more for drugs in the higher tiers, which are brand-name and higher-cost specialty drugs. You can find cost information in your health plan's list of covered drugs (also called a formulary).

What is step therapy?

Step therapy helps patients save money by first trying generic drugs to treat medical conditions. Generic drugs are approved by the FDA and are just as effective as brand-name drugs. Sometimes a patient may not respond well to a medication (brand-name or generic) and will need to try something different. In step therapy, if that is the case, the patient can ask to move (or “step”) up to another brand-name or higher-cost medication. You can learn more about step therapy, in our pharmacy section.