Frequently Asked Questions - Blue Cross Blue Shield EPO

What is an Exclusive Provider Organization (EPO)?
An Exclusive Provider Organization is designed for integration of a healthcare plan, health providers and an insurance company. An EPO plan manages cost by improving quality and health of members by using select providers (networks). An EPO plan promotes quality through transparency initiatives and policies that promote member health and manage the care members receive. An EPO plan often covers services in-network with network providers and has $0 benefits for out-of-network.


What makes an EPO plan different from a PPO?
EPO -- stands for Exclusive Provider Organization -- is similar to an in that it is a healthcare plan that covers eligible services from providers and facilities inside a network. Generally, an EPO does not pay for any services from out-of-network providers and facilities except in emergency or urgent care situations, which is similar to an HMO. Unlike an HMO, EPO participants are not usually required to have a primary care physician or referrals.

PPO -- stands for Preferred Provider Organization -- is a healthcare plan that allows people to see doctors or get services that are not part of a network. Those out-of-network services are at a higher rate, though. Plans are structured so that members will pay less money out-of-pocket when they use in-network providers.


What is used to determine eligibility for an EPO?

Eligibility for participation in an EPO is based on the defined EPO service area and whether the employee resides in that service area. 


I am enrolled in the Blue Cross Blue Shield EPO and Flexible Spending Account (FSA). How can I get reimbursed under the FSA guidelines for medical claims related to my co-payments, co-insurance and deductible amounts?
The FSA claim forms can be found in the FSA section for both health care and dependant care claims. The claims can be either mailed or faxed to UnitedHealthcare. The address and fax number are located at the top of the form.


If I choose an EPO, does the spousal surcharge apply?

Yes. If a spouse has access to group insurance coverage through his/her employer, and chooses to decline that coverage to enroll in a Caterpillar healthcare plan, then the spousal surcharge will apply.


How many cards will I receive (dental, vision, healthcare) when participating in the EPO plan?

You will receive three cards. A medical ID card from Blue Cross Blue Shield, a prescription drug ID card from Magellan Rx (the pharmacy benefit manager) and a dental ID card from Cigna. (You will receive two of each if you have spouse, child or family coverage.) VSP does not provide ID cards - just tell your provider you have VSP.


If I'm covered by the Blue Cross Blue Shield EPO, who do I contact for questions about claims, preauthorization or benefit coverage?

Refer to your Blue Cross Blue Shield ID card, call 1-844-CAT-BCBS (1-844-228-2227) or log on to the Blue Cross Blue Shield website at bcbsil.com/caterpillar.


Do co-payments count toward the out-of-pocket maximum?
Yes. Co-payments and co-insurance do apply to the out-of-pocket maximum.


Do co-payments count toward the deductible?
No. Co-payments do not count toward the individual or family deductible.


Are co-payments under the Blue Cross Blue Shield medical coverage waived once the out-of-pocket maximum is satisfied?
Yes, for the remainder of the calendar year.

If I want a second opinion, is that a covered service?
Yes. If you want a second opinion, contact Blue Cross Blue Shield Customer Service at 1-844-CAT-BCBS (844-228-2227) for more information. The customer service representative can help you find an in-network provider.


How do I find doctors or hospitals in the Blue Cross Blue Shield EPO network?

To find a provider, you can use Castlight or BCBS's website: bcbsil.com/caterpillar > Provider Finder. You can also call 1-884-CAT-BCBS (844-228-2227) for network providers.


What if I use a doctor or hospital that isn't in the network?
Blue Cross Blue Shield EPO will not cover any benefits to out-of-network providers. You will be responsible for the entire cost of the claims.


How are prescription drugs covered?

Under the BCBS EPO, prescription drug coverage is administered by Caterpillar’s prescription benefit manager, OptumRx (Magellan Rx starting 1/1/19). All participants who enroll in the Blue Cross Blue Shield EPO will use the Caterpillar Drug Formulary.


What is provided for dental coverage? 
The dental coverage is the same as the Caterpillar PPO dental plan and is administered by Cigna. You will receive a dental ID card from Cigna.


Is chiropractic care covered by the Blue Cross Blue Shield EPO plan? Are there chiropractors in the network?

Yes. Contact Blue Cross Blue Shield for preauthorization requirements and network providers.


If I travel and require healthcare while away, will it be covered?
As a plan participant, emergency medical services outside of the Blue Cross Blue Shield EPO network are always covered, with no preauthorization required.* If you're unsure if your condition warrants emergency attention, contact Blue Cross Blue Shield at 844-CAT-BCBS (844-228-2227). Routine care sought outside of the network is not covered.

*The definition of a medical emergency is based on the perspective of an ordinarily prudent layperson. Services are covered if you could reasonably expect the absence of medical attention to result in placing your health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.


Am I covered if I travel outside the United States?
As a Blue Cross Blue Shield member, you and your covered dependents can receive treatment while traveling, including outside the United States. However, many healthcare benefit plans have requirements for notifying your doctor and/or Blue Cross Blue Shield for emergency and non-emergency treatment. Contact BCBS for your specific coverage guidelines while away from home.


Will the Blue Cross Blue Shield EPO plan cover emergency room visits?

Yes, but you will pay the full negotiated rate for ambulance and ER services until you meet your deductible, then you will pay co-insurance. For an ER visit, you also pay an extra $125 fee, which is waived if you are admitted as an inpatient. Non-emergency care should be treated at the physician office or urgent care facility to avoid the higher out-of-pocket costs.


How does Medicare coverage work with my benefits under the Blue Cross Blue Shield EPO plan?

If you are on the Caterpillar Group Plan and qualify for Medicare, Medicare serves as your primary insurance and the Blue Cross Blue Shield EPO plan as your secondary insurance. Blue Cross Blue Shield will only pay after Medicare has paid for the claim or service. You will need to enroll in Medicare Part A and Part B.


Why aren’t the physician office co-pays listed on my ID card?
Co-payment amounts are not typically listed on EPO plan ID cards. Co-payment information is available to you and your providers by contacting Blue Cross and Blue Shield Customer Service at 844-CAT-BCBS (844-228-2227). You can also find benefit information on Blue Access for Members, your secure member portal. Log in or register at bcbsil.com/caterpillar.


My dependents (spouse and child(ren)) are not listed on my ID card. Should I get ID cards for them?
Members with single coverage receive one card and members with family coverage receive two cards. Only the primary policyholder's (also called "Subscriber") name appears on the ID card. If additional cards are needed for family members, contact Blue Cross and Blue Shield Customer Service at 844-CAT-BCBS (844-228-2227). Additional ID cards can also be requested through Blue Access for Members, your secure member portal. Log in or register at bcbsil.com/caterpillar.
 

I received a bill for a facility charge when I went to the doctor? Why?
If you receive services at a doctor's office that is located in or associated with a hospital, it is possible that facility will bill you a separate "facility charge" in addition to your doctor visit copayment. This is a valid charge; deductible and/or co-insurance will apply according to the terms of your plan. 


What if I am a retiree eligible for the Health Reimbursement Account (HRA)? Can I keep my medical benefit with Blue Cross Blue Shield?
You must enroll in at least one plan through Via Benefits (formerly OneExchange) for the first year and establish your HRA account. Once this has been established, you may choose to purchase any plan on your own.


Why do the website and other materials refer to Blue Cross Blue Shield of Illinois?
Blue Cross Blue Shield of Illinois is the location of the claims processing center and customer service center. However, Blue Cross Blue Shield EPO is offered to all members throughout the United States as long as the member resides in one of the designated zip codes for Blue Cross Blue Shield.