CHP for Seminary Students       Email   Print
Medical Care Benefits – Preferred Provider Organization (PPO)

 
Medical Benefits

A Preferred Provider Organization (PPO) administered by 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.

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


Network Benefit Member Pays...

Non-Network Benefit Member Pays...

Individual Deductible

$500

$1,000

Family Deductible          
 $1,000  $2,000

Coinsurance

20%

40%

Individual Coinsurance Maximum

$3,000

$7,000

Family Coinsurance Maximum
$6,000
 $14,000

Preventive Care

$0

100%

Office visits (other than preventive care)

$25 copay

$50 copay

Well baby and child care (under age 6)

$0

100%

Inpatient and Outpatient Hospitalization & Other Medical Expenses 

20% after deductible

40% after deductible

Emergency Room Visit

$100 copay (waived if admitted) 

$100 copay (waived if admitted)

Urgent Care
 $25 copay
 $50 copay

Lifetime Maximum

Unlimited lifetime maximum and includes all CHP-eligible benefits.


Prescription Drug Expenses

Administered by Express Scripts: 800-789-7488.

Click here to view the 2014 Express Scripts Preferred Drug List
Click here to view the 2014 Preferred Drug List Exclusions
Click here to view the 2014 Specialty Drug List
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 2014 Quantity Limit List of Drugs
Click here for Step Therapy Information
Click here for Step Therapy Programs and First-line/Second-line Medications
Click here for Prescription Drug Benefits Frequently Asked Questions

Acute/Short-Term Therapy Drugs and first two fills of Maintenance/Long-Term Drugs Purchased at a local pharmacy:

  • Supply of 30 days or less 
  • Limited to two 30-day fills of same prescription

Member copays:

  • Generic, $10
  • Brand-name formulary, $25
  • Non-formulary*, $50

Maintenance/Long-Term Drugs Purchased at local pharmacy:

  • Supply of 30 days or less, starting with the third fill
  • Unlimited refills as prescribed by your physician

Member copays:

  • Generic, $20
  • Brand-name formulary, $50
  • Non-formulary*, $100

Maintenance/Long-Term Drugs through Express Scripts Preferred Home Delivery:

  • Up to 90-day supply
  • Unlimited refills as prescribed by your physician

Member copays:

  • Generic, $20
  • Brand-name formulary, $50
  • Non-formulary*, $100

*A formulary is a list of prescription medications chosen by Express Scripts for their ability to be clinically and cost effective.

Note:  A new prescription is required every 12 months from the physician.

 

Mental Health and Substance Abuse Care Benefits

Administered by Cigna Behavioral Health: 866-726-5267


Network Cost

Non-Network Cost

Individual Deductible
$0

$0

Family Deductible

$0

$0

Coinsurance

0%

0%

Outpatient Individual & Group therapy

$25 copay
$50 copay

Outpatient Psychological & Lab testing

0%

0%

Emergency Room Visit
      $100 copay     
(waived if admitted)  
$100 copay
(waived if admitted)

Inpatient care

0%

0%

Other Expenses                           
    0%       0%


Dental Care Benefits

Administered by Cigna Dental: 800-244-6224

 

Network Benefits Member Pays…

Non-Network Benefit Member Pays...

CLASS I:  Preventive and Diagnostic Care
Oral exam (two per calendar year), cleanings (one every six months), two sets of bitewing x-rays per year, one set of full mouth or panoramic x-rays every three years, fluoride application (two per calendar year for persons under 19), sealants (limited to posterior tooth, only for persons under age 16, one treatment per tooth every three years), space maintainers (limited to non-orthodontic treatment), emergency care to relieve pain and dental x-rays required for the diagnosis or treatment of a dental defect, injury, or disease.

$0

 10%

CLASS II:  Basic Restorative Services
Fillings, root canal therapy, osseous surgery, periodontal scaling and root planing, denture adjustments or repairs, oral surgery (including tooth extactions), anesthesia, repairs to bridges, crowns, and inlays

20% after $50 deductible

30% after $50 deductible 

CLASS III:  Major Restorative Services
Crowns, inlays, onlays, bridges, full and partial dentures, and implants. 

50% after $50 deductible

 50% after $50 deductible

CLASS IV:  Orthodontia
Treatment and installation of orthodontic appliances for correction of irregularities in tooth position and jaw relationship (for dependent children only). 

50%

50%
CLASS V:  TMJ Treatment
Temporomandibular joint (TMJ) disorder will be covered under dental benefits only if deemed by Cigna Dental to be a dental expense instead of medical expense.
20% after $50 deductible 30% after $50 deductible 
The annual maximum for Class II, III, and V is $1,500 per person. Preventive care is not subject to the annual benefit maximum.
The lifetime maximum for Class IV is $1,250 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 Concordia Health Plan (CHP) does not provide coverage under Preventive Care Services for the following:
 
• Contraceptive methods and counseling
• Counseling for Domestic Violence
• Counseling for HIV

For members in a CHP PPO Option, Counseling for Domestic Violence and HIV are covered under the CHP behavioral health benefit administered by Cigna Behavioral Health. For members in Option HDHP, behavioral health benefits are administered by Blue Cross Blue Shield of Minnesota.


Blue Cross Blue Shield Preventive Care Recommendations

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). 

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.


Shingles Vaccine Coverage
The shingles vaccine is covered at 100% under preventive care with a network PPO provider for Concordia Health Plan (CHP) members age 50 and older. It is also covered at 100% by Express Scripts if administered by the pharmacist at a network pharmacy. The Food and Drug Administration (FDA) lowered the age of who could receive the vaccine without requiring a prescription from 60 to 50 in March 2011.


Seasonal Flu Vaccine Coverage 

Express Scripts
During flu season (from October 1 through June 1), members can present their Express Scripts prescription drug card at a retail pharmacy that participates in the Express Scripts vaccine network and receive the seasonal flu vaccine. (This includes the FluMist nasal flu vaccine spray as well as the shot.) There would be no up-front cost to the member, and it would be covered at 100% by the Concordia Health Plan.

If a member receives the vaccine at a pharmacy that does not participate in the Express Scripts vaccine network, the member would pay for the costs associated with the vaccine and submit a manual claim to Express Scripts for reimbursement.

Blue Cross Blue Shield of Minnesota
If a member receives the seasonal flu vaccine at a participating provider’s office, it would be covered at 100% under all of our medical plans with BCBS, and the member would not have to pay up front or submit any paperwork.

If a member receives the vaccine at any other provider (including community clinics), the member should pay for any costs associated with the vaccine and submit a manual claim to Blue Cross for reimbursement. When submitting a claim, the member should include a receipt showing the name and address of the provider, the date of service, the type of service (seasonal flu vaccine), and the charge for the service.