Do I have to use a PPO contracting doctor or hospital?
No, but in order to receive the highest level of benefits, members should use PPO network doctors and hospitals whenever possible. Members can seek treatment from non-PPO doctors and hospitals; however, benefits will be at the non-PPO benefit level and will be subject to usual and customary allowed amounts. Additionally, doctors and hospitals who are not contracted are allowed to balance bill you for fees that exceed usual and customary amounts. |
What if I can’t find a PPO doctor or hospital in my area?
If you are having difficulty locating a PPO doctor or hospital, please contact the Blue Cross and Blue Shield of Illinois (BCBSIL) Group Medical Customer Service Unit at (888) 652-4013. Customer Service Representatives can help you locate a PPO doctor or hospital or initiate a review to determine if a PPO waiver might be appropriate. |
What is a PPO waiver?
A PPO waiver allows eligible charges provided by a non-PPO doctor or hospital to be reimbursed at the PPO benefit level; however, eligible charges will be subject to usual and customary allowed amounts. |
When is a PPO Waiver Appropriate?
There are two scenarios whereby a PPO Waiver might be appropriate:
A Geographic Waiver applies when there is no PPO doctor, of a particular specialty, available within 20 miles of the subscriber's home Zip code.
A Clinical Waiver applies when a member requests to use a specific non-PPO doctor in lieu of available PPO doctor, based on a belief that the available PPO doctors are not able to treat the particular illness in question. |
What do I need to do if I need to be hospitalized?
Prior to any scheduled inpatient hospitalization and within two business days of an emergency hospitalization, Group Medical Plan members must call Blue Cross and Blue Shield of Illinois Pre-admission Utilization Review at (888) 652-4013. This call can be made by:
- The member
- The doctor
- The hospital
- Family or friends of the patient
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What happens if the Pre-admission Utilization Review call is not made?
Members who do not make the call, or have it made on their behalf, within the appropriate time frame will be assessed a $100 Utilization Management Charge. |
What do I do in case of an emergency?
In the event of a medical emergency, contact 911. Members should seek treatment at the nearest appropriate facility. For emergency care, benefits will be paid at the PPO benefit level, regardless of the facility used. |
Where can I get information on the prescription drug benefits under the Group Medical Plan?
Prescription drug benefits are administered by either Caremark or Prime Therapeutics, depending upon the Plan Option chosen.
Members enrolled in Agent Plan Options 2A or 3A should contact Prime Therapeutics. The toll-free number for Prime Therapeutics is (888) 652-4013. Representatives are available Monday through Friday from 7:00 a.m. to 11:00 p.m., Saturday and Sunday from 7:30 a.m. to 8:00 p.m., Central time. Agents and pharmacists are also on call after hours for urgent assistance.
Members enrolled in all other Plan Options can contact Caremark for questions concerning prescription drug benefits. The toll-free number for Caremark’s customer service unit is (800) 388-2058. Representatives are available 24 hours a day, 7 days a week.. Members can also access the Caremark Web site for more information. |
Is the Group Medical Plan still a State Farm policy?
Yes, even though Blue Cross and Blue Shield of Illinois will be processing our claims, the Group Medical Plan will continue to be a State Farm policy. State Farm will determine the benefits and rates. In addition, State Farm will continue to have final appeal authority. |
What do I do if my current doctor is not contracted in the PPO network?
For associates enrolling in the Group Medical Plan for
the first time, you may be eligible to temporarily continue treatment
with that doctor and receive the in-network benefit level.
If you believe that you have a situation which may qualify for
this special handling, contact the BCBSIL Group Medical Customer
Service Unit at (888) 652-4013. In order to qualify for this transitional
benefit, you must contact BCBSIL prior to the start of the new
Plan year (by December 31, 2009).
Examples of medical condition that may meet the guidelines:
- Pregnancy (if confirmed prior to January 1, 2010)
- Patients whose hospitalization continues beyond December 31,
2009
- Terminal illness where life expectancy is less than six months
- Chemotherapy/Radiation therapy
- Physical therapy
Examples of medical conditions that would not meet the guidelines:
- Routine care (immunizations, physicals)
- Chronic conditions which are stabilized (asthma, diabetes)
- Minor illness (flu, sprains)
- Elective surgery
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How will the new Preventive Care Benefit work?
Each individual age 17 and over has a $1000 benefit for
charges incurred for preventive care and/or services. Eligible
preventive care charges will be reimbursed at 100 percent of the
eligible charge when rendered by PPO doctors and hospitals and
60 percent of the eligible charge when rendered by non-PPO doctors
and hospitals. This benefit is not subject to the deductible,
or applied to the out-of-pocket expense limit.
Examples of preventive diagnostic tests and services include, but are not limited to, screening mammography, serum cholesterol test, resting electrocardiogram (EKG); tetanus and influenza immunizations; cervical smear or Pap smear test, fecal occult blood test, prostate specific antigen test (PSA), and bone mineral density screening. |
What number should I call to reach a Customer Service Representative?
You can reach a member of the Group Medical Customer Service Unit at (888) 652-4013. Customer Service Representatives are available Monday – Friday from 7:00 a.m. to 5:00 p.m. CT. |
How can I check the status of my claim?
You can check claim status several different ways. You can call a Customer Service Representative toll-free at (888) 652-4013. They can advise you on the status of any processed claims, as well as those that are still being considered. You can also check claim status via Blue Access for Members. |
How do I add a dependent to my coverage?
To add a new dependent to your coverage, you need to contact the State Farm Human Resources Service Center (HRSC) at (877) 272-1999. Newly acquired dependents must be added within 31 days of the qualifying event. |
I’ve lost my ID card. What do I do?
Contact the Group Medical Customer Service Unit at (888) 652-4013 to request a replacement ID card. Members can also obtain replacement ID cards by visiting Blue Access for Members. |
Do I need to submit my charges using a claim form?
When you receive care from a PPO network doctor or hospital, you don’t need to file a claim. If you receive services from a non-PPO doctor or hospital who won’t file your claim, you can download a form to submit your charges. |
How can I find a PPO network doctor or hospital?
You can search the online list of Doctors & Hospitals for information on contracting doctors and hospitals. With it, you can search for PPO doctors and hospitals in your area, or search for a specific doctor by name. You can also print out your search results in a customized report. |
Will my family members receive their own identification cards?
State Farm Group Medical Plan participants with "member only" coverage are sent one identification (ID) card. Participants with "member-plus-one" or "family coverage" receive two ID cards. If additional cards are needed, you can obtain them by contacting the Group Medical Customer Service Unit at (888) 652-4013. Members can also request additional ID cards by visiting Blue Access for Members. |
How do I change my name, address, or dependent information?
To change information on your coverage such as your name, address, or to add a new dependent, you will need to contact the State Farm Human Resources Service Center (HRSC) at (877) 272-1999. Members have 31 days from the qualifying event to add new dependents to their coverage. |
How does the $100 Emergency Room Visit Charge work?
For each visit to the emergency room, the first $100 of the facility charge is your responsibility. This charge is not applied to the deductible and does not help satisfy annual out-of-pocket expense limits. |
