Frequently Asked Questions

What is the BlueCard PPO Program?

The BlueCard PPO program allows you freedom of choice when selecting a doctor, outpatient facility, or hospital, even outside of Alabama. This program allows members to access the Preferred Provider Organization (PPO) networks available in each state that participates in the BlueCard PPO Program. When a member receives services from a PPO provider, these services are considered in-network services and enhanced benefits are available. When a member receives services from a non-PPO provider (a physician who does not participate in the PPO program) these services are considered out-of-network services and are covered under Major Medical benefits after your calendar year deductible.

In Alabama, the PPO network is comprised of Preferred Medical Doctors (PMD), so you can continue to use your PMD physician and receive the same benefits as you received previously under the Preferred Care program. If your provider is not PMD and the services being rendered are PPO services, the allowance for these services will be reduced to 80% of the PPO fee schedule after the calendar year deductible. You will be responsible for any amount over the PPO fee schedule, the 20% coinsurance, and the deductible, if applicable.

If the service is not considered a PPO service (no network is available), out-of-network benefits will be applicable.

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How will I know if my physician is a PPO provider?

In Alabama, all PMD (participating) physicians are considered PPO (participating) providers. To ensure that your physician is a participating provider, visit or contact Customer Service at 1-800-824-0435. For participating provider information outside Alabama, visit or call 1-800-810-BLUE (2583).

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What will I pay for a physician visit?

Blue Cross and Blue Shield of Alabama provides excellent benefits for physicians office visits. After you make a $30 copayment for the office visit and a $5.00 copayment on each lab service performed, Blue Cross reimburses the doctor 100% for the services you receive when visiting a Preferred Provider.

If the physician you see is not one of the over 6,000 Preferred Providers, you still receive an excellent reimbursement of 80 percent of the Usual, Customary and Reasonable charge after your deductible is met.

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What is my deductible?

When you visit a Preferred Provider, there is no deductible required. PEEHIP's major medical deductible is $300 per member or $900 per family each year. The Public Education Employees' deductible is one of the lowest around.

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What's my coverage for an emergency room visit?

Rest assured knowing that if you need to visit an emergency room, you will be covered. With Preferred Providers, accidents are covered at 100%.

All emergency accident treatment is covered at 100% of the usual, customary and reasonable cost if treatment is received within 72 hours of the accident, with a $500 maximum. With Preferred Providers, true medical emergency illness is covered at 100% subject to a $150 facility copayment.

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What happens if I receive benefits at an outpatient facility?

When you take advantage of a Preferred Outpatient Facility, you save money because you only play a small copayment amount for the services you receive.

Here are your Preferred Outpatient Facility Benefits:

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What is my coverage for a hospital visit?

Blue Cross and Blue Shield provides excellent hospitalization benefits with little out-of-pocket expense to you. With a Preferred Provider Inpatient Hospitalization, covered services are paid in full, subject to a $200 per admission hospital deductible and a $25 daily copayment for days 2-5 for 365 days without dollar limit. You are responsible for the difference between semi-private accommodations and other non-medical items, such as TV or phone.

All admissions will be subject to Preadmission Certification by completing a Blue Cross and Blue Shield of Alabama Preadmission Certification form. Emergency room admissions must be certified by the first business day following the admission by calling 1 800 248-2342.

Coverage is provided for a rehabilitation facility for one admission per illness or accident, per lifetime with a 60 day maximum. Precertification is required.

For Outpatient Hospital visits a $150 facility copayment is required for outpatient surgery and a $150 facility copayment is required for true medical emergencies. There is no copayment required for accident related services furnished within 72 hours after the accident.

When using a facility or physician that in not part of the Preferred Care network, your Major Medical benefits pay 80% of the surgeon, physician visits and anesthesiologist after the $300 individual or $900 family deductible has been met or the $200 per admission hospital deductible and $25 daily copayment for days 2-5 has been made for facility charges.

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Do I have coverage for mammogram screening?

When you take advantage of our Preferred Medical Doctor program, your mammogram is covered at 100 percent. Coverage is provided for one mammogram for women between the ages of 35-39, and one mammogram every year for women 40 or over.

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What kind of maternity benefits are offered?

Your Public Education Employees' Health Insurance Plan provides excellent benefits for maternity care and you will have very little out of pocket expense.

Preferred Provider-Covered in full.

Major Medical-when not using a Preferred Provider, paid at 80% after the deductible.

$200 per admission hospital deductible and $25 daily copayment for days 2-5.

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What is the Baby Yourself Program?

A program offered by Blue Cross and Blue Shield of Alabama to ensure your baby and you receive the best possible care during your pregnancy. With this program you have a registered nurse monitoring your pregnancy and making sure you and your baby have every thing you need for good health. This benefit is particularly important for high-risk pregnancies.

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Does my coverage include well child care?

Blue Cross and Blue Shield's Preferred Provider Program allows you to receive expanded benefits for well child care at 100%. You have 9 visits during your child's first 2 years of life, 1 visit per year age 2-6 (based on birth year) and one visit per calendar year age 7 and older

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Do I have coverage for routine childhood immunizations?

Knowing that prevention is a key to good health, Blue Cross and Blue Shield will pay your child's routine immunizations in full at your Preferred Physician.

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What are my benefits if I receive chiropractic care?

PEEHIP offers very good coverage if you need to visit a chiropractor. If you visit a Participating Chiropractor, covered services are paid at 80% of the allowed amount with no deductible. You will not have to file claims and you will never owe more than 20 percent of the allowed amount.

If you do not use a Participating Chiropractor, the services will be subject to the Major Medical deductible and paid at 80% of the allowed amount. You may also have to file the claim and you will be responsible for any difference between the charged amount and the allowed amount (in addition to your deductible and coinsurance.)

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What coverage does the Public Employees Health Plan offer for Mental Health and Substance Abuse?

You have excellent benefits for mental health or substance abuse treatment.

The first step to take is to visit one of the certified Community Mental Health Centers. They will be able to refer you to any of the approved facilities. Any hospital admission must be precertified by Blue Cross and Blue Shield of Alabama. Click here for a list of Certified Community Mental Health Centers or look in the back of your benefit booklet.

For Inpatient Preferred Provider Treatment:

Copayments for:

For Outpatient Treatment with a Preferred Provider:

$10 copayment per visit

This includes expanded coverage for outpatient care, individual therapy/counseling, family therapy/counseling, emergency services, hospital based treatment, alcohol abuse counseling and residential treatment for alcohol and drug abuse (limited to one admission per benefit period and two per lifetime) when you visit a PPO provider.

Outpatient Major Medical Care (if you chose not to visit a Preferred Provider): Is paid at 50% of the usual, customary and reasonable (UCR) charge after meeting your deductible.

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What kind of coverage do I have for accidents?

Hopefully, you won't need them, but if you do, Blue Cross provides excellent accidental injury benefits. Coverage is provided at 100% of usual, customary and reasonable charges up to a $500 maximum per injury for services provided within 90 days of the accident. Charges over $500 are covered under Major Medical at 80% after the calendar year deductible.

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What if I, or one of my covered family members, needs home health care?

In Alabama you have full coverage with no deductible when using a Preferred Provider for home health nursing, home IV therapy and home phototherapy. There is no coverage in Alabama when a non-Preferred Provider is used.

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What are my benefits for long term care?

Services are covered in full, with no deductibles when using a Preferred Provider for hospice services, equipment, supplies and drugs furnished to a terminally ill member. There is no coverage in Alabama when a non-Preferred Provider is used. All services must be preauthorized by calling 1 800 821-7231, including services provided in and outside Alabama.

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What kind of coverage do I have for prescription drugs?

Prescription drug benefits are provided through MedImpact and Walgreens Specialty Pharmacy. When you choose a Participating Pharmacy, you pay either $6 for covered generic drugs or $7 for covered generic drugs if filled at Walgreens pharmacies, $40 for covered Preferred Brand name drugs and $60 for covered non-Preferred Brand name drugs.

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What is Individual Case Management?

This is a benefit that offers alternatives to lengthy hospitalizations and is designed to provide the patient with the best environment for recovery and the most cost effective long term arrangement. A Blue Cross and Blue Shield of Alabama registered nurse monitors your care and makes sure you are in the best environment possible for recovery. All decisions are made with the consent of the patient, family and physician. This includes a Disease Management program for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease.

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