Medical Care Benefits – Preferred Provider Organization (PPO)

Call toll-free:  Blue Cross Blue Shield of Minnesota: 800-793-6922
Members receive greater benefits if they access care through a physician in the network and use network providers for health services. The member does not have to select a primary care physician and can self-refer to any specialist physician in the network. If non-network providers are used, benefits are still payable but at a lower percentage and after a deductible is satisfied.

• Option A
• Option B
• Option C
• Option D
• Prescription Drug Expense
• Mental Health and Substance Abuse Care Benefits
• Dental Care Benefits: Applies to CHP Option A - D, CDHP
• Preventive Care

 
Option A
To see a complete summary of benefits for this option, click here.

Option B
To see a complete summary of benefits for this option, click here.

Option C
To see a complete summary of benefits for this option, click here.

Option D
To see a complete summary of benefits for this option, click here.

Prescription Drug Expenses

Administered by Express Scripts
Contact Express Scripts toll-free: 800-789-7488
Click here to view the 2010 Express Scripts Formulary
Click here to view the CuraScript List of Specialty Drugs
Click here to view a listing of Drugs/Supplies Not Covered by CHP
Click here to view a listing of Drugs requiring prior authorization
Click here to view the Quantity Limit List of Drugs
Click here for Step Therapy Information
Click here for Step Therapy Programs and First-line/Second-line Medications

Mental Health and Substance Abuse Care Benefits

Network Manager:  CIGNA Behavioral Health 866-726-5267

	In-Network Cost	Out-of-Network Cost
Individual deductible	$0	$400
Family deductible	$0	$800
Coinsurance	10%	30%
Individual coinsurance maximum	$500	$1,750
Family coinsurance maximum	$1,000	$3,500
Outpatient therapy	$20 copay	30% after deductible
Outpatient testing	10%, no deductible	30% after deductible
Inpatient care	10%, no deductible	30% after deductible

Dental Care Benefits

Network Manager:  CIGNA Dental 800-CIGNA24 (244-6224)

	Network BenefitsMember Pays…
Preventive Dental Care Oral exam (two per calendar year), cleaning (two per calendar year), two sets of bitewing x-rays per calendar year, one set of full mouth or panoramic x-rays every three years, fluoride application (one per calendar year for persons under age 19), sealants (limited to posterior tooth, only for persons under age 16, one treatment per tooth every three calendar years), space maintainers (limited to non-orthodontic treatment), emergency care to relieve pain, palliative (emergency) treatment, and dental x-rays required for the diagnosis or treatment of a dental defect, injury, or disease.	$0
Basic Dental Care Fillings, extractions, inlays, onlays, crowns, root canal, therapy, bridgework, initial installation or replacement, of complete or partial dentures, denture adjustments or repairs, periodontal scaling and root planing, osseous surgery, and anesthesia. Temporomandibular joint (TMJ) disorder will be included under Basic Dental Care only if deemed by CIGNA Dental to be a dental expense instead of medical expense. Denture replacement will be covered only if it has been more than five years since the installation of the denture being replaced, whether or not the replaced denture was installed or furnished while the person was a member or enrolled dependent.	20% after deductible*
Oral Surgery Any incision or excision procedure on the gums or tissues of the mouth performed in connection with the extraction or repair of teeth, including related services if otherwise included as an eligible charge under the plan. Implant services will be considered to be oral surgery. If the charges for implant services are not deemed to be medically necessary by CIGNA Dental, the Alternate Benefit provision will be applicable for the prosthetic being placed on the implant and no reimbursement will be made towards the charges for placement of the implant.	20% after deductible*
Orthodontia Treatment and installation of orthodontic appliances for correction of irregularities in tooth position and jaw relationship (for adults and dependent children).	50% after deductible*
*Annual dental deductible is $100 per individual/$300 per family unit. The annual maximum for preventive and basic dental care is $1,500 per person. The lifetime maximum for orthodontia is $1,500 per person.

Preventive Care

Medical Care
If provided or authorized by a network physician, expenses for routine physical exams, well baby & child care, immunizations, mammograms, etc., are covered at 100%.

Blue Cross Blue Shield Preventive Care Guidelines

The above guidelines are provided as recommended preventive care, however your physician should always check with the network manager to verify coverage.

If care is secured from a physician who is not in the managed care network, charges for such care are not covered.

If a preventive doctor’s visit or screening reveals a potential medical concern, the purpose of your visit, for billing purposes, could change from preventive care to medical treatment or diagnosis.

Concordia Plan Services has prepared a preventive care notice that you can share with your doctor, explaining the preventive care billing process. We encourage you to print this notice and take it with you to your preventive care visits. 

Provider Preventive Care Notice

Dental Care
Expenses for a routine dental checkup, including teeth cleaning and x-rays, are reimbursed at 100% (but no more than two exams and/or cleanings every calendar year and no more than two sets of bitewing x-rays in a calendar year). Benefits paid are subject to the annual reimbursement limit of $1,500 per calendar year.

Good dental care may be linked with a decreased risk of pre-term birth. CIGNA Dental has provided an informational flyer on the importance of good oral health for pregnant women.